-
Benjamin Planquette,
Jean-Francois Timsit,
Benoit Misset,
Carole Schwebel,
Elie Azoulay,
Christophe Adrie,
Aurélien Vesin,
Samir Jamali,
Jean-Ralph Zahar,
Bernard Allaouchiche,
Bertrand Souweine,
Michael Darmon,
Anne-Sylvie Dumenil,
Dany Goldgran-Toledano, Bruno Mourvillier,
Jean-Pierre Bédos
[show abstract]
[hide abstract]
ABSTRACT: Introduction. The predictive factors of treatment failure for Ventilator-Acquired Pneumonia (VAP) due to Pseudomonas aeruginosa (PA) remain uncertain. Methods. From the multicenter Outcomerea database (1997-2011), PA-VAP onset and recurrence were recorded. All suspected VAP were confirmed by a positive quantitative culture of a respiratory sample. Multidrug resistant PA strains was defined by the resistance to 2 antibiotics among piperacillin, ceftazidime, imipenem, colistine and fluoroquinolones (FQ). An extensively resistant (XDR) PA was defined by resistance to piperacillin, ceftazidime, imipenem, and FQ. A treatment failure was defined as a PA-VAP recurrence or by the death occurrence. Results. 314 patients presented 393 PA-VAP. Failure occurred for 112 of them, including 79 recurrences. Susceptible, MDR and XDR PA represented 53.7%, 32% and 14.3% of the samples, respectively. Factors associated with treatment failure were: age (p=0.02), presence of at least one chronic illness (p=0.02), limitation of life support (p=0.0004), a high SOFA score (p<.0001), PA-bacteremia (p=0.003) and previous use of FQ before the first PA-VAP (p=0.0007). The failure risk was not influenced by the strain resistance profile or by the bi-antibiotic treatment, but decreased in case of VAP treatment that includes FQ (subdistribution hazard ratio sHR 0.5 [0.3-0.7]; p=0.0006). However, the strain resistance profile slows down the ICU discharge hazard (sHR 0.6 [0.4-1.0] p=0.048). Conclusion. Neither resistance profile nor bi-antibiotic therapy decreased the risk of PA-VAP treatment failure. However, the profile of PA resistance prolonged the length of stay. The potential benefit of an initial treatment containing FQ needs further randomized trials.
American Journal of Respiratory and Critical Care Medicine 05/2013; · 11.08 Impact Factor
-
Djillali Annane,
Jean-Francois Timsit,
Bruno Megarbane,
Claude Martin,
Benoit Misset, Bruno Mourvillier,
Shidasp Siami,
Jean-Luc Chagnon,
Jean-Michel Constantin,
Franck Petitpas, [......],
Xavier Forceville,
Claire Charpentier,
Antoine Tesniere,
Jean Chastre,
Julien Bohe,
Gwenhael Colin,
Alain Cariou,
Alain Renault,
Christian Brun-Buisson,
Bellissant Eric
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: A decade after drotrecogin alfa activated (DAA) was released on the market worldwide, its benefit-to-risk ratio remains a matter of debate. OBJECTIVE: The current investigator-led trial was designed to evaluate the efficacy and safety of DAA, in combination with low-dose steroids, in adults with persistent septic shock. METHODS: This was a multicenter (24 intensive care units), placebo-controlled, double-blind, 2x2 factorial design trial in which adults with persistent septic shock and no contraindication to DAA were randomly assigned to DAA alone (24 microgram per kilogram per hour for 96 hours), hydrocortisone and fludrocortisone alone, their respective combinations or their respective placebos. Primary outcome was mortality rate at day-90. MEASUREMENTS AND RESULTS: On October 25 2011, the trial was suspended following the withdrawal from the market of DAA. The Scientific Committee decided to continue the trial according to a two-parallel group design comparing low-dose steroids with their placebos and to analyze the effects of DAA on patients included before trial suspension. At the time trial was suspended, 411 patients had been recruited, 208 had received DAA and 203 had received its placebo. There was no significant interaction between DAA and low-dose steroids (P=0.47). At day-90, there were 99/208 (47.6%) deaths in patients with DAA and 94/203 (46.3%) deaths in patients with its placebo (P=0.79). There was no evidence for a difference between DAA and its placebo for any secondary outcomes or serious adverse events. CONCLUSION: In adults with established and severe septic shock, DAA showed no evidence of benefit or harm. Clinical trial registration information available at www.clinicaltrials.gov, i.d. NCT00625209.
American Journal of Respiratory and Critical Care Medicine 03/2013; · 11.08 Impact Factor
-
Tài Pham,
Alain Combes,
Hadrien Rozé,
Sylvie Chevret,
Alain Mercat,
Antoine Roch, Bruno Mourvillier,
Claire Ara-Somohano,
Olivier Bastien,
Elie Zogheib,
Marc Clavel,
Adrien Constan,
Jean-Christophe Marie Richard,
Christian Brun-Buisson,
Laurent Brochard
[show abstract]
[hide abstract]
ABSTRACT: RATIONALE: Many patients with severe acute respiratory distress syndrome (ARDS) caused by influenza A(H1N1) infection received Extracorporeal Membrane Oxygenation (ECMO) as a rescue therapy. OBJECTIVES: To analyze factors associated with death in ECMO-treated patients and the influence of ECMO on ICU mortality. METHODS: Data from patients admitted for (H1N1)-associated ARDS to French Intensive Care Units (ICU) were prospectively collected from 2009 to 2011 through the national REVA registry. We analyzed factors associated with in-ICU death in ECMO recipients, and the potential benefit of ECMO using a propensity-score (PS) matched (1:1) cohort analysis. MEASUREMENTS AND MAIN RESULTS: 123 patients received ECMO. By multivariate analysis, increasing values of age, lactate and plateau pressure under ECMO were associated with death. Of 103 patients receiving ECMO during the first week of mechanical ventilation, 52 could be matched to non-ECMO patients of comparable severity, using a one-to-one matching and using controls only once. Mortality did not differ between the two matched cohorts (OR=1.48; 95%CI [0.68-3.23], p=0.32). Interestingly, the 51 ECMO patients who could not be matched were younger, had lower PaO2/FiO2 ratio, higher plateau pressure, but also a lower ICU mortality rate than the 52 matched ECMO patients (22% vs. 50%, p=0.005). CONCLUSION: Under ECMO, an ultra protective ventilation strategy minimizing plateau pressure may be required to improve outcome. When patients with severe A(H1N1)-related ARDS treated with ECMO were compared to conventionally-treated patients, no difference in mortality rates existed. The unmatched, severely hypoxemic and younger ECMO-treated patients had, however, a lower mortality.
American Journal of Respiratory and Critical Care Medicine 11/2012; · 11.08 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVES: Cerebral toxoplasmosis remains a common neurologic complication in patients with AIDS. In this study, we aimed to characterize the prognosis of patients with HIV infection with severe forms of cerebral toxoplasmosis and to investigate the effects of adjunctive steroids on outcomes. METHODS: We carried out a retrospective cohort study (2000-2011) on consecutive patients with cerebral toxoplasmosis admitted to the medical intensive care unit (ICU) of 5 hospitals. Functional prognosis was graded at 3 months using the modified Rankin Scale (mRS). RESULTS: We studied 100 patients with a CD4 cell count of 25 (8-62) cells/μL and a Glasgow Coma Scale (GCS) score of 11 (6-14). At follow-up, 51 patients had an mRS score of 0-2 (functional independence), 30 had an mRS score of 3-5 (severe disability), and 19 had an mRS score of 6 (death). Compared with other specific treatments, the use of pyrimethamine-sulfadiazine was associated with improved survival (p = 0.03). Two factors present at ICU admission were independently associated with a poor outcome (mRS score >2) at 3 months: a CD4 cell count <25 cells/μL (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.1-6.7) and a GCS score ≤8 (OR 3.1, 95% CI 1.2-7.7). In patients treated with pyrimethamine-sulfadiazine, the use of adjunctive steroids to treat cerebral edema associated with focal lesions appeared safe but was not associated with better neurologic outcomes. CONCLUSION: Severe forms of cerebral toxoplasmosis in patients with HIV infection are characterized by a good prognosis in approximately 50% of cases. Profound immunodepression and impaired consciousness represent major determinants of outcome. In our study, the benefit of adjunctive steroids to treat cerebral edema could not be demonstrated.
Neurology 10/2012; 79(17):1762-1766. · 8.31 Impact Factor
-
Jean François Timsit,
Olivier Mimoz, Bruno Mourvillier,
Bertrand Souweine,
Maïté Garrouste-Orgeas,
Serge Alfandari,
Gaétan Plantefeve,
Régis Bronchard,
Gilles Troche,
Remy Gauzit, [......],
Julien Bohe,
Alain Lepape,
Aurélien Vesin,
Xavier Arrault,
Carole Schwebel,
Christophe Adrie,
Jean-Ralph Zahar,
Stéphane Ruckly,
Caroline Tournegros,
Jean-Christophe Lucet
[show abstract]
[hide abstract]
ABSTRACT: Rationale. Most vascular catheter-related infections (CRIs) occur extraluminally in ICU patients. Chlorhexidine-impregnated and strongly adherent dressings may decrease catheter colonization and CRI rates. Methods. In a 2:1:1 assessor-blinded randomized trial in patients with vascular catheters inserted for an expected duration of 48 hours or more in 12 French ICUs, we compared chlorhexidine dressings, highly adhesive dressings, and standard dressings, from May 2010 to July 2011. Co-primary endpoints were major-CRI with or without catheter-related bloodstream infection (CR-BSI) with chlorhexidine vs. non-chlorhexidine dressings and catheter colonization rate with highly adhesive non-chlorhexidine vs. standard non-chlorhexidine dressings. Catheter-colonization, CR-BSIs and skin reactions were secondary endpoints. Results. 1879 patients (4163 catheters, 34,339 catheter-days) were evaluated. With chlorhexidine dressings, the major-CRI rate was 67% lower (0.7/1000 vs. 2.1/1000 catheter-days; hazard ratio [HR], 0.328; 95% confidence interval [95%CI], 0.174-0.619 P=0.0006) and the CR-BSI rate 60% lower (0.5/1000 vs. 1.3/1000 catheter-days; HR, 0.402; 95%CI, 0.186-0.868, P=0.02) than with non-chlorhexidine dressings; decreases were noted in catheter colonization and skin colonization rates at catheter removal. The contact dermatitis rate was 1.1% with and 0.29% without chlorhexidine. Highly adhesive dressings decreased the detachment rate to 64.3% vs. 71.9% (P<0.0001) and the number of dressings per catheter to 2 (1-4) vs. 3 (1-5) (P<0.0001) but increased skin colonization (P<0.0001) and catheter colonization (HR=1.650; 95%CI, 1.21-2.26; P=0.0016) without influencing CRI or CR-BSI rates. Conclusion. A large randomized trial demonstrated that chlorhexidine-gel impregnated dressings decreased the CRI rate in ICU patients with intravascular catheters. Highly adhesive dressings decreased dressing detachment but increased skin and catheter colonization. Clinical trial registration information available at www.clinicaltrials.gov, i.d. NCT01189682.
American Journal of Respiratory and Critical Care Medicine 10/2012; · 11.08 Impact Factor
-
Jean-Christophe Marie Richard,
Tài Pham,
Christian Brun-Buisson,
Jean Reignier,
Alain Mercat,
Gaëtan Beduneau,
Bernard Régnier, Bruno Mourvillier,
Christophe Guitton,
Matthias Castanier,
Alain Combes,
Yves Le Tulzo,
Laurent Brochard
[show abstract]
[hide abstract]
ABSTRACT: INTRODUCTION: The specific burden imposed on Intensive Care Units (ICUs) during the A/H1N1 influenza 2009 pandemic has been poorly explored. An on-line screening registry allowed a daily report of ICU beds occupancy rate by flu infected patients (Flu-OR) admitted in French ICUs. METHODS: We conducted a prospective inception cohort study with results of an on-line screening registry designed for daily assessment of ICU burden. RESULTS: Among the 108 centers participating to the French H1N1 research network on mechanical ventilation (REVA) - French Society of Intensive Care (SRLF) registry, 69 ICUs belonging to seven large geographical areas voluntarily participated in a website screening-registry. The aim was to daily assess the ICU beds occupancy rate by influenza-infected and non-infected patients for at least three weeks. Three hundred ninety-one critically ill infected patients were enrolled in the cohort, representing a subset of 35% of the whole French 2009 pandemic cohort; 73% were mechanically ventilated, 13% required extra corporal membrane oxygenation (ECMO) and 22% died. The global Flu-OR in these ICUs was only 7.6%, but it exceeded a predefined 15% critical threshold in 32 ICUs for a total of 103 weeks. Flu-ORs were significantly higher in University than in non-University hospitals. The peak ICU burden was poorly predicted by observations obtained at the level of large geographical areas. CONCLUSIONS: The peak Flu-OR during the pandemic significantly exceeded a 15% critical threshold in almost half of the ICUs, with an uneven distribution with time, geographical areas and between University and non-University hospitals. An on-line assessment of Flu-OR via a simple dedicated registry may contribute to better match resources and needs.
Critical care (London, England) 07/2012; 16(4):R118. · 4.61 Impact Factor
-
Clinical Infectious Diseases 03/2012; 55(1):160-1. · 9.15 Impact Factor
-
Lila Bouadma,
François Barbier,
Lucie Biard,
Marina Esposito-Farèse,
Bertrand Le Corre,
Annick Macrez,
Laurence Salomon,
Christine Bonnal,
Caroline Zanker,
Christophe Najem, Bruno Mourvillier,
Jean Christophe Lucet,
Bernard Régnier,
Michel Wolff,
Florence Tubach
[show abstract]
[hide abstract]
ABSTRACT: Influenza-vaccination rates among healthcare workers (HCW) remain low worldwide, even during the 2009 A(H1N1) pandemic. In France, this vaccination is free but administered on a voluntary basis. We investigated the factors influencing HCW influenza vaccination.
In June-July 2010, HCW from wards of five French hospitals completed a cross-sectional survey. A multifaceted campaign aimed at improving vaccination coverage in this hospital group was conducted before and during the 2009 pandemic. Using an anonymous self-administered questionnaire, we assessed the relationships between seasonal (SIV) and pandemic (PIV) influenza vaccinations, and sociodemographic and professional characteristics, previous and current vaccination statuses, and 33 statements investigating 10 sociocognitive domains. The sociocognitive domains describing HCWs' SIV and PIV profiles were analyzed using the classification-and-regression-tree method.
Of the HCWs responding to our survey, 1480 were paramedical and 401 were medical with 2009 vaccination rates of 30% and 58% for SIV and 21% and 71% for PIV, respectively (p<0.0001 for both SIV and PIV vaccinations). Older age, prior SIV, working in emergency departments or intensive care units, being a medical HCW and the hospital they worked in were associated with both vaccinations; while work shift was associated only with PIV. Sociocognitive domains associated with both vaccinations were self-perception of benefits and health motivation for all HCW. For medical HCW, being a role model was an additional domain associated with SIV and PIV.
Both vaccination rates remained low. Vaccination mainly depended on self-determined factors and for medical HCW, being a role model.
PLoS ONE 01/2012; 7(7):e38646. · 4.09 Impact Factor
-
Sébastien Perbet,
Nicolas Mongardon,
Florence Dumas,
Cédric Bruel,
Virginie Lemiale, Bruno Mourvillier,
Pierre Carli,
Olivier Varenne,
Jean-Paul Mira,
Michel Wolff,
Alain Cariou
[show abstract]
[hide abstract]
ABSTRACT: Although frequent, little is known about early-onset pneumonia that occurs in the postresuscitation period. Although induced hypothermia is recommended as a method of improving neurological outcome, its influence on the occurrence of early-onset pneumonia is not well defined.
To describe the incidence, risk factors, causative agents, and impact on outcome of early-onset pneumonia occurring within 3 days after out-of-hospital cardiac arrest (OHCA).
Retrospective analysis of a large cohort study of all patients successfully resuscitated after OHCA and admitted from July 2002 to March 2008 in two medical intensive care units (ICUs). Patients who presented accidental hypothermia or a known pneumonia before OHCA, or patients who died within the first 24 hours, were excluded.
During this 6-year period, 845 patients were admitted after OHCA, and 641 consecutive patients were included. A total of 500 patients (78%) were treated with therapeutic hypothermia. In the first 3 days, 419 (65%) presented early-onset pneumonia. Multivariate analysis disclosed therapeutic hypothermia as the single independent risk factor of early-onset pneumonia (odds ratio, 1.90; 95% confidence interval, 1.28-2.80; P = 0.001). Early-onset pneumonia increased length of mechanical ventilation (5.7 ± 5.9 vs. 4.7 ± 6.2 d; P = 0.001) and ICU stay (7.9 ± 7.2 versus 6.7 ± 7.6 d; P = 0.001), but did not influence incidence of ventilator-associated pneumonia (P = 0.25), favorable neurologic outcome (P = 0.35), or ICU mortality (P = 0.26).
After OHCA, therapeutic hypothermia is associated with an increased risk of early-onset pneumonia. This complication was associated with prolonged respiratory support and ICU stay, but did not significantly influence ICU mortality.
American Journal of Respiratory and Critical Care Medicine 08/2011; 184(9):1048-54. · 11.08 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: ABSTRACT: Patients with infective endocarditis (IE) are generally referred to the intensive care unit (ICU) for one or more organ dysfunctions caused by complications of IE. Neurologic events are frequent causes of ICU admission in patients with IE. They can arise through various mechanisms consisting of stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Occlusion of cerebral arteries, with stroke or transient ischemic attack, accounts for 40% to 50% of the central nervous system complications of IE. CT scan is the most easily feasible neuroimaging in critically unstable patients. However, magnetic resonance imaging is more sensitive and when performed should follow a standardized protocol. In patients with ischemic stroke who are already receiving oral anticoagulant therapy, this treatment should be replaced by unfractionated heparin for at least 2 weeks with a close monitoring of coagulation tests. Mounting evidence shows that, for both complicated left-sided native valve endocarditis and Staphylococcus aureus prosthetic valve endocarditis, valve replacement combined with medical therapy is associated with a better outcome than medical treatment alone. In a recent series, approximately 50% of patients underwent valve replacement during the acute phase of IE before completion of antibiotic treatment. After a neurological event, most patients have at least one indication for cardiac surgery. Recent data from literature suggest that after a stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Neurologic complications of IE contribute to a severe prognosis in ICU patients. However, patients with only silent or transient stroke had a better prognosis than patients with symptomatic events. In addition, more than neurologic event per se, a better predictor of mortality is neurologic dysfunction, which is associated with location and extension of brain damage. Patients with severe neurological impairment and those with brain hemorrhage have the worse outcome.
Annals of intensive care. 01/2011; 1(1):10.
-
[show abstract]
[hide abstract]
ABSTRACT: Ventilator-associated pneumonia (VAP), the most common hospital-acquired infection in intensive care units, increases mortality and health care costs. We describe the long-term impact of a multifaceted program for decreasing VAP rates that markedly improved compliance with 8 targeted preventive measures. Methods: We compared VAP rates during a 45-month baseline period and a 30-month intervention period in a cohort of patients who received mechanical ventilation for > 48 h. VAP was diagnosed on the basis of quantitative cultures of distal specimens. VAP incidence density rates were expressed as total VAP episodes over total mechanical ventilation duration and as first VAP episodes over mechanical ventilation duration at VAP or hospital discharge. We used segmented regression analysis and a Cox proportional hazard model to assess the impact of the program on first VAP occurrence.
Baseline and intervention VAP rates were 22.6 and 13.1 total VAP episodes over total mechanical ventilation duration per 1000 ventilation-days, respectively, and 26.1 and 14.9 first VAP episodes over mechanical ventilation duration at VAP or hospital discharge per 1000 procedure-days, respectively (P < .001). VAP rates decreased by 43% in both statistical analyses and remained significant after adjustment for confounders (Cox adjusted hazard ratio, 0.58; 95% confidence interval, 0.46-0.72; P < .001). Daily VAP hazard rates on ventilation days 5, 10, and 15 were 2.6%, 3.5%, and 3.4%, respectively, during the baseline period and 1.4%, 2.3%, and 2%, respectively, during the intervention period.
Our preventive program produced sustained VAP rate decreases in the long term. However, VAP rates remained substantial despite high compliance with preventive measures, suggesting that eliminating VAP in the intensive care unit may be an unrealistic goal.
Clinical Infectious Diseases 10/2010; 51(10):1115-22. · 9.15 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the proportion of preventable hospital-acquired bloodstream infections (HA-BSIs), the authors prospectively examined consecutive cases in a large university hospital over an 18-month period.
Medical charts were assessed with the physician in charge of the patient within 4 days after HA-BSI diagnosis to determine whether the infection was healthcare-related. Preventability was assessed using a validated tool. Results of 378 HA-BSIs (incidence rate, 1.00 per 1000 patient-days), 341 were first HA-BSI episodes in a patient, and 272 (79.8%) were secondary to an identifiable source, of whom 196 (57.5%) were related to medical management. These 196 HA-BSIs were related to an invasive procedure (n=163), a non-invasive medical management (n=30) or both (n=3).
Of the 272 patients with HA-BSIs from identifiable sources, 55 (20.2%) had no underlying disease, 115 (42.3%) had an ultimately fatal underlying disease, 99 (36.4%) had a rapidly fatal disease, and three (1.1%) were not evaluated. Of the 196 iatrogenic HA-BSIs, 66 were considered preventable (most of them being related to an intravascular catheter), 84 were of uncertain preventability, and 46 were not preventable. In total, 66 of the 341 HA-BSIs (19.4%) were considered preventable, and 191 (56.0%) were not preventable.
Although evaluation of the preventability of hospital-associated adverse events has been reported to be difficult and of limited reliability, our simple method may help to identify wards or HA-BSI types that warrant in-depth evaluation.
Quality and Safety in Health Care 10/2010; 19(5):e30. · 1.68 Impact Factor
-
Stéphane Legriel,
Elie Azoulay,
Matthieu Resche-Rigon,
Virginie Lemiale, Bruno Mourvillier,
Achille Kouatchet,
Gilles Troché,
Manuel Wolf,
Richard Galliot,
Géraldine Dessertaine,
Danièle Combaux,
Frederic Jacobs,
Pascal Beuret,
Bruno Megarbane,
Pierre Carli,
Yves Lambert,
Fabrice Bruneel,
Jean-Pierre Bedos
[show abstract]
[hide abstract]
ABSTRACT: Few outcome data are available about convulsive status epilepticus managed in the intensive care unit. We studied 90-day functional outcomes and their determinants in patients with convulsive status epilepticus.
Two hundred forty-eight convulsive status epilepticus patients admitted to 18 intensive care units in 2005-2007 were included in a prospective observational cohort study. The main outcome measure was a Glasgow Outcome Scale score of 5 (good recovery) on day 90.
Convulsive status epilepticus occurred out of hospital in 177 (67%) patients, and all but 15 patients were still seizing at medical team arrival. The median time from convulsive status epilepticus onset to anticonvulsant drug initiation was 40 mins (interquartile range, 5-80). Total seizure duration was 85 mins (interquartile range, 46.5-180). Convulsive status epilepticus was refractory in 49 (20%) patients. The most common causes of convulsive status epilepticus were anticonvulsive agent withdrawal (36.4%) in patients with previous epilepsy and stroke (27.7%) in inaugural convulsive status epilepticus. Mechanical ventilation was needed in 210 (85%) patients. On day 90, 42 (18.8%) patients were dead, 87 (38.8%) had marked functional impairments (Glasgow Outcome Scale score, 2-4), and 95 (42.4%) had a good recovery (Glasgow Outcome Scale score, 5). Factors showing independent positive associations with poor outcome (Glasgow Outcome Scale score, <5) were older age (odds ratio, 1.04/year; 95% confidence interval, 1.02-1.05; p=.0005), cerebral insult (odds ratio, 2.70; 95% confidence interval, 1.37-5.26; p=.007), longer seizure duration (odds ratio, 1.72/120 min; 95% confidence interval, 1.05-2.86; p=.03), on-scene focal neurologic signs (odds ratio, 2.08; 95% confidence interval, 1.03-4.16; p=.04), and refractory convulsive status epilepticus (odds ratio, 2.70; 95% confidence interval, 1.02-7.14; p=.045).
Ninety days after intensive care unit admission for convulsive status epilepticus, half the survivors had severe functional impairments. Longer seizure duration, cerebral insult, and refractory convulsive status epilepticus were strongly associated with poor outcomes, suggesting a role for early neuroprotective strategies.
Critical care medicine 09/2010; 38(12):2295-303. · 6.37 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Prevention of ventilator-associated pneumonia (VAP) requires a complex approach that should include factors affecting healthcare workers' (HCWs) behavior. This study attempted to assess change of individual factors throughout a multifaceted program focusing on VAP prevention.
The prevention program involved all HCWs in a 20-bed medical intensive care unit (ICU) and included a multidisciplinary task force, an educational session, direct observations and performance feedback, technical improvements, and reminders. Knowledge, beliefs, and perceptions (cognitive factors) were assessed with a test and a self-reporting questionnaire based on social-cognitive theories. They were completed before and 1 and 12 months after the educational session.
Of the 100 HCWs initially evaluated, 84 were present 1 year later. Overall, individual factors (knowledge and cognitive factors) changed positively and significantly, immediately after the educational session. Five cognitive factors were significantly associated with knowledge: perceived susceptibility, seriousness, knowledge, benefits, and self-efficacy (P < 0.05). The other factors, i.e., perceived barriers, subjective and behavioral norm, intention to perform action, and motivation, were not. The positive cognitive change was significantly reinforced at 1 year. Three distinct cognitive profiles derived from answers to the baseline questionnaire were individualized. The positive impact of our behavioral approach was highest for the HCW group with the lowest baseline cognitive profiles.
Behavior changed gradually throughout the program and was especially pronounced for HCWs with the lowest baseline cognitive profiles.
European Journal of Intensive Care Medicine 08/2010; 36(8):1341-7. · 5.17 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the effect of a 2-yr multifaceted program aimed at preventing ventilator-acquired pneumonia on compliance with eight targeted preventive measures.
Pre- and postintervention observational study.
A 20-bed medical intensive care unit in a teaching hospital.
A total of 1649 ventilator-days were observed.
The program involved all healthcare workers and included a multidisciplinary task force, an educational session, direct observations with performance feedback, technical improvements, and reminders. It focused on eight targeted measures based on well-recognized published guidelines, easily and precisely defined acts, and directly concerned healthcare workers' bedside behavior. Compliance assessment consisted of five 4-wk periods (before the intervention and 1 month, 6 months, 12 months, and 24 months thereafter).
Hand-hygiene and glove-and-gown use compliances were initially high (68% and 80%) and remained stable over time. Compliance with all other preventive measures was initially low and increased steadily over time (before 2-yr level, p < .0001): backrest elevation (5% to 58%) and tracheal cuff pressure maintenance (40% to 89%), which improved after simple technical equipment implementation; orogastric tube use (52% to 96%); gastric overdistension avoidance (20% to 68%); good oral hygiene (47% to 90%); and nonessential tracheal suction elimination (41% to 92%). To assess overall performance of the last six preventive measures, using ventilator-days as the unit of analysis, a composite score for preventive measures applied (range, 0-6) was developed. The median (interquartile range) composite scores for the five successive assessments were 2 (1-3), 4 (3-5), 4 (4-5), 5 (4-6), and 5 (4-6) points; they increased significantly over time (p < .0001). Ventilator-acquired pneumonia prevalence rate decreased by 51% after intervention (p < .0001).
Our active, long-lasting program for preventing ventilator-acquired pneumonia successfully increased compliance with preventive measures directly dependent on healthcare workers' bedside performance. The multidimensional framework was critical for this marked, progressive, and sustained change.
Critical care medicine 03/2010; 38(3):789-96. · 6.37 Impact Factor
-
Maité Garrouste-Orgeas,
Jean François Timsit,
Aurelien Vesin,
Carole Schwebel,
Patrick Arnodo,
Jean Yves Lefrant,
Bertrand Souweine,
Alexis Tabah,
Julien Charpentier,
Olivier Gontier,
Fabienne Fieux, Bruno Mourvillier,
Gilles Troché,
Jean Reignier,
Marie Françoise Dumay,
Elie Azoulay,
Bernard Reignier,
Jean Carlet,
Lilia Soufir
[show abstract]
[hide abstract]
ABSTRACT: Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention.
We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality.
We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales.
Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15.4%) in 128 (9.3%) patients were adverse events that were followed by one or more clinical consequences (n = 163) or that required one or more procedures or treatments (n = 58). By multivariable analysis, having two or more adverse events was an independent risk factor for ICU mortality (odds ratio, 3.09; 95% confidence interval, 1.30-7.36; P = 0.039).
The impact of medical errors on mortality indicates an urgent need to develop prevention programs. We have planned a study to assess a program based on our results.
American Journal of Respiratory and Critical Care Medicine 10/2009; 181(2):134-42. · 11.08 Impact Factor
-
Benoît Misset,
Didier Nakache,
Aurélien Vesin,
Mickael Darmon,
Maïté Garrouste-Orgeas, Bruno Mourvillier,
Christophe Adrie,
Sébastian Pease,
Marie-Aliette Costa de Beauregard,
Dany Goldgran-Toledano,
Elisabeth Métais,
Jean-François Timsit
[show abstract]
[hide abstract]
ABSTRACT: Administrative coding of medical diagnoses in intensive care unit (ICU) patients is mandatory in order to create databases for use in epidemiological and economic studies. We assessed the reliability of coding between different ICU physicians.
One hundred medical records selected randomly from 29,393 cases collected between 1998 and 2004 in the French multicenter Outcomerea ICU database were studied. Each record was sent to two senior physicians from independent ICUs who recoded the diagnoses using the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision (ICD-10) after being trained according to guidelines developed by two French national intensive care medicine societies: the French Society of Intensive Care Medicine (SRLF) and the French Society of Anesthesiology and Intensive Care Medicine (SFAR). These codes were then compared with the original codes, which had been selected by the physician treating the patient. A specific comparison was done for the diagnoses of septicemia and shock (codes derived from A41 and R57, respectively).
The ICU physicians coded an average of 4.6 +/- 3.0 (range 1 to 32) diagnoses per patient, with little agreement between the three coders. The primary diagnosis was matched by both external coders in 34% (95% confidence interval (CI) 25% to 43%) of cases, by only one in 35% (95% CI 26% to 44%) of cases, and by neither in 31% (95% CI 22% to 40%) of cases. Only 18% (95% CI 16% to 20%) of all codes were selected by all three coders. Similar results were obtained for the diagnoses of septicemia and/or shock.
In a multicenter database designed primarily for epidemiological and cohort studies in ICU patients, the coding of medical diagnoses varied between different observers. This could limit the interpretation and validity of research and epidemiological programs using diagnoses as inclusion criteria.
Critical care (London, England) 08/2008; 12(4):R95. · 4.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite recent management guidelines, no recent study has evaluated outcomes in ICU patients with status epilepticus (SE).
An 8-year retrospective study.
Observational study in 140 ICU patients with SE, including 81 (58%) with continuous SE and 59 (42%) with intermittent SE (repeated seizures without interictal recovery).
The 95 men and 45 women had a median age of 49 years (IQR 24-71). Median seizure time was 60 min (IQR 20-180), and 58 patients had seizures longer than 30 min. The SE was nonconvulsive in 16 (11%) patients and convulsive in 124 (89%), including 89 (64%) with tonic-clonic generalized seizures, 27 (19%) with partial seizures, 7 (5%) with myoclonic seizures, and 1 with tonic seizures. The most common causes of SE were cerebral insult in 53% and anticonvulsant drug withdrawal in 20% of patients. No cause was identified in 35% of patients. Median time from SE to treatment was 5 min (IQR 0-71). The SE was refractory in 35 (25%) patients. Mechanical ventilation was needed in 106 patients. Hospital mortality was 21%. By multivariate analysis, independent predictors of 30-day mortality were age (OR 1.03/year; 95% CI 1.00-1.06), GCS at scene (OR 0.84/point; 95% CI 0.72-0.98), continuous SE (OR 3.17; 95% CI 1.15-8.77), symptomatic SE (OR 4.08; 95% CI 1.49-11.10), and refractory SE (OR 2.83; 95% CI 1.06-7.54).
Mortality in SE patients remains high and chiefly determined by seizure severity. Further studies are needed to evaluate the possible impact of early maximal anticonvulsant treatment on outcomes.
Intensive Care Medicine 04/2008; 34(3):476-80. · 5.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Because acute disseminated encephalomyelitis (ADEM) is a rare disease in adults admitted to the intensive care unit (ICU), we describe its characteristics and patient outcomes.
A retrospective (2000-2006), observational, multicenter study was conducted in seven medical ICUs. Clinical, biological and neuroimaging features of patients diagnosed with ADEM were evaluated. Functional prognosis was graded using the modified Rankin (mR) scale.
None.
At ICU admission, the 20 patients' median (25th-75th percentile) Glasgow coma score (GCS) was 7 (4-13), temperature 39 (38-39) degrees C. Six (30%) patients had seizures, 17 (85%) had a motor deficit and 14 (70%) required mechanical ventilation. Fifteen (75%) patients had cerebrospinal fluid pleocytocis. All patients had white-matter lesions on their magnetic resonance images. All patients received high-dose steroids. Five (25%) patients died. Fourteen (70%) patients were able to walk without assistance (mR<or=3) at follow-up [7 (3-9) months]. Compared to the latter, patients who died or were severely disabled at the follow-up evaluation [6 (30%) patients, mR>3] had significantly lower GCS (4 (3-4) vs. 12 (7-13), p=0.002) and more frequent seizures [4 (67%) vs. 2 (14%), p=0.02] at admission.
Unlike previous reports, our results showed that ADEM requiring ICU admission is a severe disease causing high mortality, and 35% of the patients had persistent functional sequelae. Intensivists should be aware of ADEM's clinical features to initiate appropriate immunomodulating therapy.
Intensive Care Medicine 03/2008; 34(3):528-32. · 5.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Evidence from a recent randomized controlled trial suggests that dexamethasone as adjunct therapy in adult pneumococcal meningitis reduces mortality and neurological sequelae. However, adding dexamethasone has the potential to reduce penetration of vancomycin into the cerebrospinal fluid (CSF). We sought to determine concentrations of vancomycin in serum and CSF of patients with suspected or proven pneumococcal meningitis receiving dexamethasone to assess the penetration of vancomycin into the CSF during steroid therapy.
In an observational open multicenter study, adult patients admitted to the intensive care unit because of suspected pneumococcal meningitis received recommended treatment for pneumococcal meningitis, comprising intravenous cefotaxime (200 mg per kg of body weight per day), vancomycin (administered as continuous infusion of 60 mg per kg of body weight per day after a loading dose of 15 mg per kg of body weight), and adjunctive therapy with dexamethasone (10 mg every 6 h). Vancomycin levels in CSF were measured on day 2 or day 3 of therapy and were correlated with protein levels in CSF and vancomycin levels in serum (determined at the same time as levels in CSF).
Fourteen patients were included. Thirteen had proven pneumococcal meningitis; 1 patient, initially suspected of having pneumococcal meningitis, was finally determined to have meningitis due to Neisseria meningitidis. Mean levels of vancomycin in serum and CSF were 25.2 and 7.2 mg/L, respectively, and were positively correlated (r=0.6; P=.025). A positive correlation was also found between the ratio of vancomycin in CSF to vancomycin in serum and the level of protein in CSF (r=0.66; P=.01).
Appropriate concentrations of vancomycin in CSF may be obtained even when concomitant steroids are used. Dexamethasone can, therefore, be used without fear of impeding vancomycin penetration into the CSF of patients with pneumococcal meningitis, provided that vancomycin dosage is adequate. This study is registered at http://www.ClinicalTrials.gov/ (registration number NCT00162578).
Clinical Infectious Diseases 02/2007; 44(2):250-5. · 9.15 Impact Factor
