[Show abstract][Hide abstract] ABSTRACT: Background:
Intensive care unit (ICU) patients are aging, and older age has been associated with higher mortality in ICU. As previous studies have reported that older age was also associated with less intensive treatment, we investigated the relationship between age, treatment intensity and mortality in medical ICU patients.
Data were extracted from the administrative database of 18 medical ICUs. Patients with a unique medical ICU stay and a Simplified Acute Physiology Score II (without age-related points) >15 were included. Treatment intensity was described with a novel indicator, which is a four-group classification based upon the most frequent ICU procedures. The relationship between age, treatment intensity and hospital mortality was analyzed with the estimation of standardized mortality ratio in the four groups of treatment intensity.
A total of 23,578 patients, including 3203 patients aged ≥80 years, were analyzed. Hospital mortality increased from 13 % for the younger patients (age < 40 years) to 38 % for the older patients (age ≥ 80 years), while Simplified Acute Physiology Score II (without age-related points) increased only from 36 (age < 40 years) to 43 (age ≥ 80). Hospital mortality increased with age in the four groups of treatment intensity. Standardized mortality ratio increased with age among the patients with less intensive treatment but was not associated with age among the patients with the highest treatment intensity.
Our results support the fact that the increase in mortality with age among ICU patients is not related to an increase in severity. Using a new tool to estimate ICU treatment intensity, our study suggests that mortality of ICU patients increases with age whatever the treatment intensity is. Further investigations are required to determinate whether this increase in mortality among older ICU patients is related to undertreatment or to a lower efficiency of organ support treatment.
Preview · Article · Dec 2016 · Annals of Intensive Care
[Show abstract][Hide abstract] ABSTRACT: Clinical features and outcomes of patients with spontaneous ilio-psoas hematoma (IPH) in intensive care units (ICUs) are poorly documented. The objectives of this study were to determine epidemiological, clinical, biological and management characteristics of ICU patients with IPH.
We conducted a retrospective multicentric study in three French ICUs from January 2006 to December 2014. We included IPH diagnosed both at admission and during ICU stay. Surgery and embolization were available 24 h a day for each center, and therapeutic decisions were undertaken after pluridisciplinary discussion. All IPHs were diagnosed using CT scan.
During this period, we identified 3.01 cases/1000 admissions. The mortality rate of the 77 included patients was 30 %. In multivariate analysis, we observed that mortality was independently associated with SAPS II (OR 1.1, 95 % CI [1.013–1.195], p = 0.02) and with the presence of hemorrhagic shock (OR 67.1, 95 % CI [2.6–1691], p = 0.01). We found IPH was related to anticoagulation therapy in 56 cases (72 %), with guideline-concordant reversal performed in 33 % of patients. We did not found any association between anticoagulant therapy type and outcome.
We found IPH is an infrequent disease, with a high mortality rate of 30 %, mostly related to anticoagulation therapy and usually affecting the elderly. Management of anticoagulation-related IPH includes a high rate of no reversal of 38 %.
Preview · Article · Dec 2016 · Annals of Intensive Care
[Show abstract][Hide abstract] ABSTRACT: Extracorporeal CO2 removal (ECCO2R) primarily ensures CO2 removal, without significant effect on oxygenation. This is possible with low or moderate extracorporeal blood flows unlike ECMO devices. It is important to consider for each ECCO2R device not only the performance in terms of CO2 elimination but also the cost and safety, including the incidence of hemorrhagic and thrombotic complications. The most convincing clinical experience has been reported in the context of ARDS and severe acute exacerbations of COPD, particularly in patients at high risk of non invasive ventilation failure. Preliminary reported clinical benefits prompt to achieve in the short term randomized controlled trials in these two major indications.
[Show abstract][Hide abstract] ABSTRACT: Background: The recent improvement of the management of patients (pts) with cancer has led to a better quality of life and also a longer survival. With the ageing of the population, admission to ICU of elderly cancer pts will be more frequently ask.
The aim of our study is to assess the short and middle term survival of elderly pts with cancer admitted to ICU.
Material and Methods: This is a retrospective unicentric study. All pts, older than 65yrs, suffering from evolutive cancer admitted to ICU were included. The elderly definition was taken according to the WHO definition. The primary endpoints were: ICU, hospitalisation and 90-day survival, and anti tumoral treatment resumption. Datas concerning cancer (type, presence and localisation of metastasis, number of antitumoral treatment), reasons for admission, severity at admission and ICU stay (need for mechanical ventilation, inotrope drugs, or dialysis) were collected.
Results: Between august 2009 and december 2012 we included 175 pts. Cancer localisations were distributed as follows: lung 30.3% (n=53), gastrointestinal 23.4% (n=41), genitourinary 22.8% (n=40), head and neck 12% (n=21), breast 6.3% (n=11) and gynaecological 5.1% (n=9). Metastatic pts represented 60% (n=105). The median IGS2 score was 64 (20–125), which predicts a 60% ICU mortality.
Sixty-six pts died in ICU (37.7%), 84 pts during hospitalisation (48% of the 175 pts), and 92 were dead at day 90 (51.4% of 157 pts). On the 91 pts ICU survivors, 53 (58.2%) had anti tumoral treatment resumption, and 27 (15.4%) had no treatment because they had localised tumor.
In multivariate analysis, factors associated with death (p<0.01) were: mechanical ventilation, administration of inotropes; high urea, lactates and creatinine blood rates, low blood pH.
Cancer type, presence and localisation of metastasis were not found as death predictive factors.
Conclusions: In our cohort, more than half of the elderly patients admitted to ICU survived. The severity of the patients at the ICU admission was related with death. Types of cancer, presence or localisation of metastasis were not associated with death. Moreover nearly half of the patients who survived the ICU were able to resume anti-tumoral treatment.
[Show abstract][Hide abstract] ABSTRACT: There is no consensus on optimal screening procedures for multidrug-resistant Enterobacteriaceae (MDRE) in intensive care units (ICUs). Therefore, we assessed five strategies for the detection of extended-spectrum beta-lactamase (ESBL) and high-level expressed AmpC cephalosporinase (HL-CASE) producers. During a 3-month period, a rectal screening swab sample was collected daily from every ICU patient, from the first 24 hours to the last day of ICU stay. Samples were plated on MDRE-selective media. Bacteria were identified using MALDI-TOF mass spectrometry and antibiograms were performed using disk diffusion. MDRE were isolated from 682/2348 (29.0%) screening samples collected from 93/269 (34.6%) patients. Incidences of patients with ESBL and HL-CASE-producers were 17.8 and 19.3 per 100 admissions, respectively. In 48/93 patients, MDRE carriage was intermittent. Compared to systematic screening at admission, systematic screening at discharge did not significantly increase the rate of MDRE detection among the 93 patients (62% versus 70%). In contrast, screening at admission and discharge, screening at admission and weekly thereafter, and screening at admission and weekly thereafter and at discharge significantly increased MDRE detection (77%, p=0.02; 76%, p=0.01; 86%, p<0.001, respectively). The difference in MDRE detection between these strategies relies essentially on the levels of detection of patients with HL-CASE-producers. The most reasonable strategy would be to collect two samples, one at admission and one at discharge, which would detect 87.5% of the ESBL-strains, 67.3% of the HL-CASE-strains and 77.4% of all MDRE-strains. This study should facilitate decision-making concerning the most suitable screening policy for MDRE detection in a given ICU setting.This article is protected by copyright. All rights reserved.
No preview · Article · May 2014 · Clinical Microbiology and Infection
[Show abstract][Hide abstract] ABSTRACT: Background: Patients aged >80 years represent a growing population admitted to intensive care units (ICUs). However, little is known about ICU-acquired infection (IAI) in this population, and the rate of invasive procedures is increasing. Aim: To evaluate the frequency and effects of IAI in elderly (>= 80 years) and younger patients. Methods: Retrospective evaluation of consecutive patients hospitalized for three days or more over a three-year period in an 18-bed ICU in an academic medical centre. Findings: Elderly patients represented 18.9% of the study population. At admission, the mean number of organ dysfunctions was similar in elderly and younger patients. The use of invasive procedures was also similar in elderly and younger patients, as follows: invasive mechanical ventilation for more than two days, 67.4% vs 55%; central venous catheterization, 56.9% vs 51.4%; and renal replacement therapy, 17.6% vs 17.8%, respectively. The frequency of IAI was 16.5% in elderly patients and 13.9% in younger patients (P = 0.28), with 20.5 vs 18.9 IAI episodes per 1000 ICU-days, respectively (P = 0.2). A Cox model identified central venous catheterization and invasive mechanical ventilation for more than two days as independent risk factors for IAI. The associations between IAI and prolonged ICU stay, increased nursing workload, and ICU and hospital mortality rates were similar in elderly and younger patients. Conclusions: The frequency of IAI was similar in elderly and younger patients, as were the associations between IAI and length of ICU stay, nursing workload and ICU mortality in an ICU with a high rate of invasive procedures.
No preview · Article · Apr 2014 · Journal of Hospital Infection
[Show abstract][Hide abstract] ABSTRACT: Apoptosis is the most common pathway of neutrophil death under both physiological and inflammatory conditions. In this study, we describe an apoptotic pathway in human neutrophils that is triggered via the surface molecule CD24. In normal neutrophils, CD24 ligation induces death through depolarization of the mitochondrial membrane in a manner dependent on caspase-3 and caspase-9 and reactive oxygen species. Proinflammatory cytokines such as TNF-alpha, IFN-gamma, and GM-CSF upregulated the expression of CD24 in vitro, favoring the emergence of a new CD16high/CD24high subset of cultured neutrophils. We observed that CD24 expression (at both mRNA and protein levels) was significantly downregulated in neutrophils from sepsis patients but not from patients with systemic inflammatory response syndrome. This downregulation was reproduced by incubation of neutrophils from healthy controls with corticosteroids or with plasma collected from sepsis patients, but not with IL-10 or TGF-beta. Decreased CD24 expression observed on sepsis neutrophils was associated with lack of functionality of the molecule, because cross-ligation of CD24 failed to trigger apoptosis in neutrophils from sepsis patients. Our results suggest a novel aspect of CD24-mediated immunoregulation and represent, to our knowledge, the first report showing the role of CD24 in the delayed/defective cell death in sepsis.
Preview · Article · Mar 2014 · The Journal of Immunology
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to describe the features of a large cohort of patients with postoperative mediastinitis, with particular regard to Gram-negative bacteria (GNB), and assess their outcome. This bicentric retrospective cohort included all patients who were hospitalized in the Intensive Care Unit with mediastinitis after cardiac surgery during a 9-year period. Three hundred and nine patients developed a mediastinitis with a mean age of 65 years and a mean standard Euroscore of six points. Ninety-one patients (29.4%) developed a GNB mediastinitis (GNBm). Of the 364 pathogens involved, 103 GNB were identified. GNBm were more frequently polymicrobial (44% versus 3.2%; p <0.001). Being female was the sole independent risk factor of GNBm in multivariate analysis. Initial antimicrobial therapy was significantly more frequently inappropriate with GNBm compared with other microorganisms (24.6% versus 1.9%; p <0.001). Independent risk factors for inappropriateness of initial antimicrobial treatment were GNBm (OR = 8.58, 95%CI 2.53-29.02, p 0.0006), and polymicrobial mediastinitis (OR = 4.52, 95%CI 1.68-12.12, p 0.0028). GNBm were associated with more drainage failure, secondary infection, need for prolonged mechanical ventilation and/or use of vasopressors. Thirty-day hospital mortality was significantly higher with GNBm (31.9 % versus 17.0%; p 0.004). GNBm was identified as an independent risk factor of hospital mortality (OR = 2.31, 95%CI 1.16-4.61, p 0.0179).
Preview · Article · Mar 2014 · Clinical Microbiology and Infection
[Show abstract][Hide abstract] ABSTRACT: Las mediastinitis consecutivas a cirugía cardíaca se definen por la presencia de pus o tejidos necróticos en el mediastino o el esternón o por la identificación de agentes patógenos en las muestras mediastínicas. La incidencia de esta afección posquirúrgica (1-1,5%) no se ha modificado desde hace unos 20 años. Los agentes patógenos causales más frecuentes son los estafilococos. Según las series, predominan Staphylococcus aureus (S. aureus) o los estafilococos coagulasa-negativos. La frecuencia de las cepas de S. aureus resistentes a la meticilina depende de la ecología de cada centro asistencial. Los principales factores de riesgo de mediastinitis son la diabetes, la obesidad, la enfermedad pulmonar obstructiva crónica (EPOC), la duración de la circulación extracorpórea, la cirugía de revascularización coronaria con arterias mamarias internas, la reintervención para hemostasia postoperatoria, la inestabilidad hemodinámica y la prolongación de la ventilación mecánica postoperatorias. El diagnóstico, que se sospecha por la presencia de signos locales (inflamación y dolor en la cicatriz) y sistémicos, debe confirmarse mediante el estudio bacteriológico de muestras mediastínicas obtenidas por punción retroesternal. El pronóstico de las mediastinitis es grave, con una mortalidad de alrededor del 20% y un aumento considerable del tiempo de hospitalización. El tratamiento consiste en la reintervención de urgencia, con un desbridamiento mediastínico y esternal minucioso. Pueden emplearse dos técnicas quirúrgicas. Las técnicas a tórax cerrado con drenaje aspirativo por drenes de redón deberían usarse en primer lugar. Las técnicas a tórax abierto, con cicatrización por presión negativa, se reservan para las formas muy graves desde el principio o tras el fracaso del tratamiento inicial. Antes de la cirugía se instaura un tratamiento antibiótico doble intravenoso. La duración total de la antibioticoterapia es de 6 semanas. Los programas de seguimiento así como los protocolos de prevención y tratamiento estandarizados de las mediastinitis permiten reducir la incidencia y mejorar el pronóstico.
[Show abstract][Hide abstract] ABSTRACT: Non invasive ventilation (NIV) has become a cornerstone therapy of acute respiratory failure and is thus increasingly used in Rationale: the intensive care unit (ICU). To date, few data are available on how caregivers, patients and their relative perceive NIV. We therefore designed a study with three distinct objectives: (1) to compare the perception of NIV use between physicians and nurses, (2) to compare the perception of NIV use among patients and their relatives, (3) to put in perspective these two sets of data. Prospective multicenter survey in 33 ICU in France and Belgium. Physicians and nurses answered to a 50 items Patients and methods: questionnaire describing their feeling and perception of NIV. During the same period, patients who received NIV during their ICU stay without being intubated (NIV success) and their relatives answered on discharge a 30-items questionnaire describing their feeling regarding NIV. Patients who did not understand French and who had delirium (CAM-ICU) were not included in the study. In questionnaires, each item was quantified from 1 (« not agree at all ») to 10 (« totally agree »). 751 nurses (29 [25-35] years old), 312 physicians (32 [28-40] years old), 396 patients (age 69 [60-80] years old, SAPS II 36 [28-42], Results : 57% male) et 145 relatives (age 59 [47-69] years old, 38 % male) were included. Compared with physicians, nurses perceived NIV as more binding and stressful (p<0.0001) and more time consuming (score 6 [4-7]). For a large majority of patients and their relatives, NIV was felt as an effective treatment (respectively 8 [6-10] and 9 [8-10], respectively), which they did not regret to have been treated with (score 1[1-3]). However, both patients and relatives described NIV as an aggressive (4[1-7]) and stressful treatment (4[1-7]), whose principles had been little explained (5[1-10]). Although both nurses, physicians perceived NIV as an efficient therapy, nurses who are closer to the patients than physicians Conclusions: during NIV sessions have a more negative perception of the tolerance and burden of care of NIV. In addition, patients who succeeded NIV and their relatives considered NIV as an effective treatment for the price of discomfort and significant trauma and complained of a lack of information on NIV. The impact of this negative perception and lack of information on care-giving and long-term psychological consequences remains to be determined. This abstract is funded by: None Am J Respir Crit Care Med 187;2013:A3092 Internet address: www.atsjournals.org Online Abstracts Issue
[Show abstract][Hide abstract] ABSTRACT: Background:
Growth-arrest-specific protein 6 (GAS6) is a vitamin K-dependent protein expressed by endothelial cells and leukocytes participating in cell survival, migration and proliferation and involved in many pathological situations. The aim of our study was to assess its implication in ARDS and its variation according to PEEP setting, considering that different cyclic stresses could alter GAS6 plasma levels.
Our subjects were enrolled in the ExPress study comparing a minimal alveolar distention (low-PEEP) ventilatory strategy to a maximal alveolar recruitment (high-PEEP) strategy in ARDS. Plasma GAS6, interleukin-8 (IL-8), and vascular endothelial growth factor (VEGF) levels were measured at day 0 and day 3 by enzyme-linked immunosorbent assay in blood samples prospectively collected during the study for a subset of 52 subjects included in 8 centers during year 2005.
We found that GAS6 plasma level was elevated in the whole population at day 0: median 106 ng/mL IQR 77-139 ng/mL, with significant correlations with IL-8, the Simplified Acute Physiology Score II and the Organ Dysfunction and Infection scores. Statistically significant decreases in GAS6 and IL-8 plasma levels were observed between day 0 and day 3 in the high-PEEP group (P = .02); while there were no differences between day 0 and day 3 in the low-PEEP group.
GAS6 plasma level is elevated in ARDS patients. The high-PEEP strategy is associated with a decrease in GAS6 and IL-8 plasma levels at day 3, without significant differences in day 28 mortality between the 2 groups. (Clinicaltrials.gov NCT00188058).
No preview · Article · Apr 2013 · Respiratory care
[Show abstract][Hide abstract] ABSTRACT: Noninvasive ventilation (NIV) is a very effective technique for severe acute exacerbations of COPD/COLD and acute pulmonary edema, but its interest is still a matter of debate for severe asthma attacks. However, despite a slow decrease in asthma mortality, which actually mainly concerns older people, the prevalence of asthma is still raising and is associated to a high level of emergency visits and ICU hospitalizations for severe asthma attacks. Unfortunately, the level of knowledge on this topic is based only on observational studies and on 4 small RCTs, likely to be underpowered to demonstrate any benefit on the rate of tracheal intubation or on mortality. Nevertheless, some benefits have been shown with regard to functional improvement and length of hospital stay. From a technical point of view, one can expect in the future some improvements by combining NIV and nebulization and/or helium-oxygen therapy. Finally, there is a need for positive large randomized clinical trials before routine clinical use can be firmly recommended.
No preview · Article · Mar 2013 · Minerva anestesiologica
[Show abstract][Hide abstract] ABSTRACT: Ventricular assist devices (VADs) have become an established therapeutic option for patients with end-stage heart failure. The appearance of heart failure in VAD patients seems unexpected. Nevertheless, this phenomenon is not rare. We report six cases of VAD patients with clinical presentation of heart failure at different times after implantation and describe the mechanisms involved. The aetiology of this heart failure, like its clinical presentation, varies and has yet to be identified. (C) 2012 Published by Elsevier Masson SAS.
Full-text · Article · Feb 2013 · Archives of cardiovascular diseases