[Show abstract][Hide abstract] ABSTRACT: Intensive care medicine is poorly recognized as a medical specialty in resource limited health sytems. Between 2000 and 2010 a French-Pakistani cooperation program in intensive care medicine was launched between the Pakistan Institute of Medical Sciences (Islamabad teaching Hospital, PIMS) and the medical intensive care unit (MICU) of Saint Antoine hospital in Paris. It allows understanding the different challenges created in Pakistan by patients requiring intensive care, the weaknesses of the public health system and the slow uprise of this medical specialty. The sociocultural context is an important factor to explain the failures and successes of this program. The interventions focused on the creation of a 9-bed medical intensive care unit organized in a closed system with a dedicated team, the advocacy for recognition of intensive care medicine as a medical specialty, the creation of one formal training program and writing of a medical department project submitted to the health ministry. Sustainability of the results achieved by this cooperation program is questionable, but we obtained the recognition of intensive care medicine as a medical specialty and young doctors are now joining specific training programs. In 2014, the MICU of PIMS still works as a closed unit.
[Show abstract][Hide abstract] ABSTRACT: To determine the evolution of the outcome of patients with cirrhosis and septic shock.
A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data.
The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area.
Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis.
Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04).
The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.
Critical care medicine 04/2014; · 6.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Weaning from mechanical ventilation is a daily challenge in intensive care patients. Our objective was to explore microcirculatory perfusion during mechanical ventilation weaning and to evaluate its predictive value on the weaning outcome. Methods: Prospective observational study. All consecutive patients, older than 18 years, under mechanical ventilation that met the criteria for weaning were enrolled. Patients underwent a Tpiece Spontaneous Breath Trial (SBT) for 60 minutes and the usual clinical parameters were recorded every 5 minutes. Microcirculatory perfusion was evaluated using the mottling score and the Tissue Oxygen Saturation (StO2) measured by Near Infrared Spectroscopy technology on the thenar and knee area. Results: Seventythree patients were studied (age: 67 15 years, men: 40, SAPS II: 47 15) after a duration of mechanical ventilation of 3 16 days. Fortyfive patients succeeded the first SBT. The mottling score severity recorded just before ventilator disconnection (baseline) was associated with weaning failure (P=0.03). Moreover, the mottling score increase during SBT was significantly associated with weaning failure (80% vs 28%, P=0.001; Odds ratio 10.5 (2.054.8)). Baseline thenar StO2 was not different according to weaning outcome (Failure 76 13% vs Success 77 7%, P=0.90) whereas baseline knee StO2 was significantly lower in patients who failed the first SBT (67 13% vs 75 12%, P<0.01). This difference was apparent since the very beginning of the SBT and lasted throughout the trial (P=0.0001). Conclusion: In unselected mechanically ventilated patients undergoing SBT, mottling score and knee StO2 are early predictors of weaning failure.
[Show abstract][Hide abstract] ABSTRACT: Mottling score has been reported to be a strong predictive factor during septic shock. However, the pathophysiology of mottling remains unclear.
In patients admitted in ICU for septic shock, we measured on the same area the mean skin perfusion by laser Doppler, the mottling score, and variations of both indices between T1 (6 hours after vasopressors were started) and T2 (24 hours later).
Fourteen patients were included, SAPS II was 56 [37--71] and SOFA score at T1 was 10 [7--12]. The mean skin surface area analyzed was 4108 +/- 740 mm2; 1184 +/- 141 measurements were performed over each defined skin surface area. Skin perfusion was significantly different according to mottling score and decreased from 37 [31--42] perfusion units (PUs) for a mottling score of [0--1] to 22 [20--32] PUs for a mottling score of [2--3] and 23 [16--28] for a score of [4--5] (Kruskal-Wallis test, P = 0.05). We analyzed skin perfusion changes during resuscitation in each patient and together with mottling score variations between T1 and T2 using a Wilcoxon signed-rank test. Among the 14 patients included, mottling score increased (worsened) in 5 patients, decreased (improved) in 5 patients, and remained stable in 4 patients. Baseline skin perfusion at T1 was arbitrarily scored 100%. Mean skin perfusion significantly decreased in all the patients whose mottling score worsened from 100% baseline to 63.2 +/- 10.7% (P = 0.001), mean skin perfusion significantly increased in all patients whose mottling score improved from 100% baseline to 172.6 +/- 46.8% (P = 0.001), and remained stable in patients whose mottling score did not change (100.5 +/- 6.8%, P = 0.95).
We have shown that mottling score variations and skin perfusion changes during septic shock resuscitation were correlated, providing additional evidence that mottling reflects skin hypoperfusion.
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to identify the predictors of brain death (BD) upon admission to the intensive care unit (ICU) of comatose patients with spontaneous intracerebral hemorrhage (ICH). Patients admitted in our ICU from 2002 to 2010 for spontaneous ICH and placed under mechanical ventilation were retrospectively analyzed. Of the 72 patients, 49% evolved to BD, 39% died after withdrawal of life support, and 12% were discharged alive. The most discriminating characteristics to predict BD were included in two models; Model 1 contained ≥3 abolished brainstem responses [adjusted odds ratios (OR) = 8.4 (2.4, 29.1)] and the swirl sign on the baseline CT-scan [adjusted OR = 5.0 (1.6, 15.9)] and Model 2 addressed the abolition of corneal reflexes [unilateral/bilateral: adjusted OR = 4.2 (0.9, 20.1)/8.8 (2.4, 32.3)] and the swirl sign on the baseline CT-scan [adjusted OR = 6.2 (1.9, 20.0)]. Two scores predicting BD were created (sensitivity: 0.89 and 0.88, specificity: 0.68 and 0.65). Risk of evolution toward BD was classified as low (corneal reflexes present and no swirl sign), high (≥1 corneal reflexes abolished and swirl sign), and intermediate. Simple signs at ICU admission can predict BD in comatose patients with ICH and could increase the potential for organ donation.
Transplant International 03/2013; · 3.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: The interdependence between endotoxemia, gram negative (GN) bacteremia and mortality has been extensively studied. Underlying patient risk and GN bacteremia types are possible confounders of the relationship. METHODS: Published studies with ≥10 patients in either ICU or non-ICU settings, endotoxemia detection by limulus assay, reporting mortality proportions and ≥1 GN bacteremia were included. Summary odds ratios (OR) for mortality were derived across all studies by meta-analysis for the following contrasts: sub-groups with either endotoxemia (group three), GN bacteremia (group two) or both (group one) each versus the group with neither detected (group four; reference group). The mortality proportion for group four is the proxy measure of study level risk within L'Abbé plots. RESULTS: Thirty-five studies were found. Among nine studies in an ICU setting, the OR for mortality was borderline (OR <2) or non-significantly increased for groups two (GN bacteremia alone) and three (endotoxemia alone) and patient group one (GN bacteremia and endotoxemia co-detected) each versus patient group four (neither endotoxemia nor GN bacteremia detected). The ORs were markedly higher for group one versus group four (OR 6.9; 95% confidence interval (CI), 4.4 -to 11.0 when derived from non-ICU studies. The distributions of Pseudomonas aeruginosa and Escherichia coli bacteremias among groups one versus two are significantly unequal. CONCLUSIONS: The co-detection of GN bacteremia and endotoxemia is predictive of increased mortality risk versus the detection of neither but only in studies undertaken in a non-ICU setting. Variation in GN bacteremia species types and underlying risk are likely unrecognized confounders in the individual studies.
Critical care (London, England) 08/2012; 16(4):R148. · 4.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous studies have shown a good agreement between central venous pressure (CVP) measurements from catheters placed in superior vena cava and catheters placed in the abdominal cava/common iliac vein. However, the influence of intra-abdominal pressure on such measurements remains unknown.
We conducted a prospective, observational study in a tertiary teaching hospital. We enrolled patients who had indwelling catheters in both superior vena cava (double lumen catheter) and femoroiliac veins (dialysis catheter) and into the bladder. Pressures were measured from all the sites, CVP, femoroiliac venous pressure (FIVP), and intra-abdominal pressure.
A total of 30 patients were enrolled (age 62 ± 14 years; SAPS II 62 (52-76)). Fifty complete sets of measurements were performed. All of the studied patients were mechanically ventilated (PEP 3 cmH20 (2-5)). We observed that the concordance between CVP and FIVP decreased when intra-abdominal pressure increased. We identified 14 mmHg as the best intra-abdominal pressure cutoff, and we found that CVP and FIVP were significantly more in agreement below this threshold than above (94% versus 50%, P = 0.002).
We reported that intra-abdominal pressure affected agreement between CVP measurements from catheter placed in superior vena cava and catheters placed in the femoroiliac vein. Agreement was excellent when intra-abdominal pressure was below 14 mmHg.
[Show abstract][Hide abstract] ABSTRACT: We assessed the potential impact of infusion tubing on blood glucose imbalance in ICU patients given intensive insulin therapy (IIT). We compared the incidence of blood glucose imbalance in patients equipped, in a nonrandomized fashion, with either conventional tubing or with a multiport infusion device.
We retrospectively analyzed the nursing files of 35 patients given IIT through the distal line of a double-lumen central venous catheter. A total of 1389 hours of IIT were analyzed for occurrence of hypoglycemic events [defined as arterial blood glucose below 90 mg/dL requiring discontinuation of insulin].
Twenty-one hypoglycemic events were noted (density of incidence 15 for 1000 hours of ITT). In 17 of these 21 events (81%), medication had been administered during the previous hour through the line connected to the distal lumen of the catheter. Conventional tubing use was associated with a higher density of incidence of hypoglycemic events than multiport infusion device use (23 vs. 2 for 1,000 hours of IIT; rate ratio = 11.5; 95% confidence interval, 2.71-48.8; p < 0.001).
The administration of on-demand medication through tubing carrying other medications can lead to the delivery of significant amounts of unscheduled products. Hypoglycaemia observed during IIT could be related to this phenomenon. The use of a multiport infusion device with a limited dead volume could limit hypoglycemia in patients on IIT.
[Show abstract][Hide abstract] ABSTRACT: To examine how the outcomes of cirrhotic patients admitted to an ICU have changed over time.
A retrospective study in a medical ICU during two separate 3-year periods [period 1 (P1): 1995-1998 and period 2 (P2): 2005-2008].
A total of 56 cirrhotic patients were admitted during P1 and 138 during P2, accounting for 2.3 and 4.5% of the total ICU admissions (P<0.01). Patients' characteristics were markedly different between the two periods: previous functional status improved (Knaus scale, A/B/C/D: P1 - 7.1%/53.6%/35.7%/3.6% vs. P2 - 28.2%/47.8%/22.5%/1.5%, P<0.01), the number of comorbidities decreased (Charlson: 1.79±2.22 vs. 1.02±1.40, P=0.02), the severity of cirrhosis increased [Child-Pugh: 8 (7-13) vs. 11 (8-13), P=0.04; Model for End-Stage Liver Disease: 16 (12-28) vs. 22 (15-31), P=0.02], and acute organ dysfunctions increased (Sequential Organ Failure Assessment: 7.3±5.6 vs. 11.3±5.5, P<0.01). The crude in-ICU mortality was similar during the two periods (39.3 vs. 41.3%, P=0.92). However, after adjustment for severity, in-ICU mortality was markedly decreased during P2 (odds ratio: 0.36 [0.15; 0.88], P=0.02).
Cirrhotic patients admitted to the ICU have an improved outcome despite increased severity of liver disease. This improvement is associated with a higher selection according to their previous functional status and comorbidities.
European journal of gastroenterology & hepatology 05/2012; 24(8):897-904. · 1.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thenar eminence tissue oxygen saturation (StO(2)) was developed to assess organ perfusion. However, mottling, a strong predictor of mortality in septic shock, develops preferentially around the knee. We aimed to evaluate the prognostic value of StO(2) measured around the knee in septic shock patients and compare it to thenar StO(2).
This was a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included. Parameters were recorded when vasopressors were started (H0) and every 6 h during 24 h. Their predictive value was assessed on 14-day mortality.
Fifty-two patients were included. SOFA score was 11 (9-15) and SAPS II was 56 (40-72). At 6 h after ICU admission (H6), mean arterial pressure, cardiac index, and central venous pressure were not different between non-survivors and survivors; but non-survivors had higher arterial lactate level (8.8 ± 5.0 vs. 2.2 ± 1.5 mmol/l, P < 0.001), lower urinary output (0.22 ± 0.45 vs. 0.70 ± 0.50 ml/kg/h, P < 0.001) and ScvO(2) (62 ± 20 vs. 72 ± 9 %, P = 0.03). At H6, StO(2) was lower in non-survivors; this difference was not significant for thenar StO(2) (70 ± 15 vs. 77 ± 12 %, P = 0.10) but was very pronounced for knee StO(2) (39 ± 23 vs. 71 ± 12 %, P < 0.001). At H6, a low knee StO(2) was associated with a higher mottling score (P < 0.01), a higher lactate level (P < 0.002, R (2) = 0.2), and a lower urinary output (P = 0.02, R (2) = 0.12).
After initial septic shock resuscitation, StO(2) measured around the knee is a strong predictive factor of 14-day mortality.
European Journal of Intensive Care Medicine 04/2012; 38(6):976-83. · 5.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes.
Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol.
Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 ± 3.1 vs. 2.7 ± 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 ± 2.3 days, P = 0.004). Number of inserted chest tubes per patient was not significantly different according to pneumothoraces' aetiology.
Small-bore chest tubes are feasible for treatment of iatrogenic pneumothoraces and have a better rate of success and slightly longer drainage duration than when used for spontaneous pneumothoraces.
[Show abstract][Hide abstract] ABSTRACT: Radiography is the criterion standard method to ensure correct placement of a feeding tube. Recently, excellent results were reported using a combination of colorimetric capnography and epigastric auscultation, but the impact of this technique has not been studied to date. Objectives were to assess whether our local procedure, using colorimetric capnography to ensure proper feeding tube placement, improves the patient's care, satisfies nurses, and decreases costs compared with the standard procedure requiring systematic radiography.
We performed a monocentric prospective observational study in a medical intensive care unit over a 4-month period. Feeding tube placement was assessed by colorimetric capnography and epigastric auscultation. Radiography was performed when epigastric auscultation was inconclusive.
A total of 69 feeding tubes were placed in 44 patients. Radiography was required in 10.1% of the cases. The new procedure decreased costs ($33.37 ± 13.96 vs $45.92, P < .0001) and was less time consuming (11.6 ± 20.5 minutes vs 87.3 ± 45.2 minutes, P < .0001) than using systematic radiography. All nurses reported confidence in the procedure, which improved the organization of their care.
The use of colorimetric capnography and epigastric auscultation to confirm feeding tube placement improves nurse's organization of care, saves time, and decreases costs.
Journal of critical care 08/2011; 26(4):411-4. · 2.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The presence of a femoral venous catheter could be associated with gas presence in the hepatic veins. This entity should be recognized to avoid a misdiagnosis of gas presence in the portal veins or in the biliary tract. Objectives are to assess: 1) the incidence of gas presence in the hepatic veins in intensive care unit patients explored by abdominal computed tomography scan; 2) the rate of gas presence in the liver in intensive care unit patients with a catheter inserted in the femoral vein; and 3) the specific imaging features.
A retrospective study in a medical intensive care unit in a teaching hospital in France.
All consecutive abdominal computed tomography scans performed in intensive care unit patients between 2008 and 2010 were retrospectively reviewed independently by an intensivist and a radiologist. Presence of gas in the liver was noticed and its location was specified using multiplanar reconstruction.
We analyzed 235 computed tomography scans (performed in 207 patients). Gas was identified in the liver on 10.2% of computed tomography scans. Gas was located in the hepatic veins in 12 cases (50%), in the biliary tract in ten cases (41.7%), and in the portal veins in two cases (8.3%). All patients with gas in the hepatic veins had a femoral venous catheter. Characteristics of gas location within the hepatic veins on computed tomography scan axial views were not different from those of gas located in the biliary tract or in the portal venous system. Gas was present in the hepatic veins in 12 of 83 (14.5%) of the computed tomography scans with a femoral venous catheter and was associated with gas presence in other vessels of the inferior vena cava system in five of 12 (41.7%) cases.
Gas located in the hepatic veins related to femoral venous catheter is a frequent cause of gas in the liver in intensive care unit patients. This imaging feature could be misleading. Multiplanar reconstruction should be performed to differentiate this aspect from those of gas in the biliary tract or in the portal venous system.
Critical care medicine 06/2011; 39(11):2447-51. · 6.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Severe infections caused by hypermucoviscous Klebsiella pneumoniae have been reported in Southeast Asian countries over the past several decades. This report shows their emergence in France, with 12 cases observed during a 2-year period in two university hospitals. Two clones (sequence type 86 [ST86] and ST380) of serotype K2 caused five rapidly fatal bacteremia cases, three of which were associated with pneumonia, whereas seven liver abscess cases were caused by K1 strains of ST23.
Journal of clinical microbiology 06/2011; 49(8):3012-4. · 4.16 Impact Factor