[Non invasive ventilation in the ICU for the neuromuscular patient: ethical issues]. / Ventilation non invasive et insuffisance respiratoire chronique d'origine neuromusculaire: implications pour l'intensiviste. Aspects ethiques.

Non-invasive mechanical ventilation in patients with chronic neuromuscular disorders is an effective tool for treating dyspnea or sleep disturbances often observed in such patients. So, NIV has to be considered as a palliative treatment and it must systematically be offered to these patients. Mechanical ventilation, non-invasive or invasive (via a trachesotomy) have to be considered systematically with patients and families at an earlier stages of these diseases in order to design a strategy in case of acute respiratory failure. In a second parent paper of this issue, we discuss the medico-legal implications of mechanical ventilation in neuromuscular failure, particularly the end-of-life aspects.

[Non invasive ventilation in the ICU for the neuromuscular patient: legal issues]. / Ventilation non invasive et insuffisance respiratoire chronique d'origine neuromusculaire: implications pour l'intensiviste. Aspects médico-légaux.

The legal frame in which chronic mechanical ventilation is placed in Switzerland and France is discussed in this article. Safety of the patients and responsibility of caregivers are considered. We also discuss the ethical and legal aspects of the end-of-life of these patients, particularly when they decide that mechanical ventilation must be interrupted because they do not more tolerate their poor quality of life, and when they deliberately decide to die.

Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology.

BACKGROUND: Open lung biopsy (OLB) is helpful in the management of patients with acute respiratory distress syndrome (ARDS) of unknown etiology. We determine the impact of surgical lung biopsies performed at the bedside on the management of patients with ARDS. METHODS: We reviewed all consecutive cases of patients with ARDS who underwent a surgical OLB at the bedside in a medical intensive care unit between 1993 and 2005. RESULTS: Biopsies were performed in 19 patients mechanically ventilated for ARDS of unknown etiology despite extensive diagnostic process and empirical therapeutic trials. Among them, 17 (89%) were immunocompromised and 10 patients experienced hematological malignancies. Surgical biopsies were obtained after a median (25%-75%) mechanical ventilation of 5 (2-11) days; mean (+/-SD) Pao(2)/Fio(2) ratio was 119.3 (+/-34.2) mm Hg. Histologic diagnoses were obtained in all cases and were specific in 13 patients (68%), including 9 (47%) not previously suspected. Immediate complications (26%) were local (pneumothorax, minimal bleeding) without general or respiratory consequences. The biopsy resulted in major changes in management in 17 patients (89%). It contributed to a decision to limit care in 12 of 17 patients who died. CONCLUSION: Our data confirm that surgical OLB may have an important impact on the management of patients with ARDS of unknown etiology after extensive diagnostic process. The procedure can be performed at the bedside, is safe, and has a high diagnostic yield leading to major changes in management, including withdrawal of vital support, in the majority of patients.

Admission of incompetent patients to intensive care: doctors' responsiveness to family wishes.

OBJECTIVE: When a patient is incompetent, the family is often considered to be a natural surrogate. The doctors' responsiveness to family wishes may vary. We explored if doctors' personal characteristics were associated with responsiveness to the relatives' wishes when admission to the intensive care unit (ICU) is considered. METHODS: In a mail survey, we asked all Swiss ICU doctors to decide on the admission of a hypothetical incompetent patient presenting with hemolytic uremic syndrome. Each participant was randomly allocated to a version of the scenario in which the family asked either that "everything be done" or that the patient be "spared useless suffering." MAIN RESULTS: Overall, 232 (60.9%) questionnaires were returned. When the family asked that "everything be done," 60% of doctors chose to admit the hypothetical patient, but when the family asked that she be spared useless suffering, only 39% did so (odds ratio [OR] 2.6, confidence interval 1.5-4.6). This OR captures responsiveness to family wishes. It varied across subgroups of ICU doctors. Characteristics associated with greater responsiveness to family wishes were older age (OR 6.0 vs. 1.2, p = 0.002), nonuniversity work setting (OR 4.2 vs. 1.0, p = 0.012), less time devoted to intensive care practice (OR 4.0 vs. 1.5, p = 0.036), and greater self-confidence in ethical knowledge (OR 3.4 vs. 1.7, p = 0.044). CONCLUSIONS: Older doctors and those working in regional hospitals were more responsive to family wishes when assessing an incompetent patient for ICU admission. These findings emphasize the need for effective advance care planning.

[Anesthetic gases for the treatment of acute severe asthma]. / Emploi de mélanges d'agents volatils dans l'asthme aigu grave.

Halogenated gases have sometimes been used for treating acute severe asthma when this disorder is refractory to any drug. Presently, we only can rely on some sparsed observations, or to small retrospective series. Isoflurane seems to be the most studied gas: it has clearly a bronchodilating action, and its side-effects seem to be minor. However, to administer such medications, precise knowledge and technical skills are mandatory. In addition, the intensive care personnel must be protected from an accidental exposure. Therefore, intensive care physicians should be helped by an experienced anesthesiologist when using these gases.

Anti-(apolipoprotein A-1) IgGs are associated with high levels of oxidized low-density lipoprotein in acute coronary syndrome.

ApoA-1 (apolipoprotein A-1) is the main component of HDL (high-density lipoprotein) and stabilizes PON-1 (paraoxonase-1), which prevents lipid peroxidation and oxLDL (oxidized low-density lipoprotein) formation. Autoantibodies against apoA-1 [anti-(apoA-1) IgG] have been found in antiphospholipid syndrome and systemic lupus erythematosous, two diseases with an increased risk of thrombotic events, as well as in ACS (acute coronary syndrome). OxLDL levels are also elevated in these diseases. Whether anti-(apoA-1) IgGs exist in other prothrombotic conditions, such as APE (acute pulmonary embolism) and stroke, has not been studied and their potential association with oxLDL and PON-1 activity is not known. In the present study, we determined prospectively the prevalence of anti-(apoA-1) IgG in patients with ACS (n=127), APE (n=58) and stroke (n=34), and, when present, we tested their association with oxLDL levels. The prevalance of anti-(apoA-1) IgG was 11% in the ACS group, 2% in the control group and 0% in the APE and stroke groups. The ACS group had significantly higher median anti-(apoA-1) IgG titres than the other groups of patients. Patients with ACS positive for anti-(apoA-1) IgG had significantly higher median oxLDL values than those who tested negative (226.5 compared with 47.7 units/l; P<0.00001) and controls. The Spearman ranked test revealed a significant correlation between anti-(apoA-1) IgG titres and serum oxLDL levels (r=0.28, P<0.05). No association was found between PON-1 activity and oxLDL or anti-(apoA-1) IgG levels. In conclusion, anti-(apoA-1) IgG levels are positive in ACS, but not in stroke or APE. In ACS, their presence is associated with higher levels of oxLDL and is directly proportional to the serum concentration of oxLDL. These results emphasize the role of humoral autoimmunity as a mediator of inflammation and coronary atherogenesis.

Fatal brain gas embolism during non-invasive positive pressure ventilation.

Gas embolism is a dreaded complication following invasive medical procedures, traumatic lung injury and decompression accidents. We report a case of fatal gas embolism following the use of non-invasive ventilation (NIV) with bilevel positive airway pressure (BiPAP). The patient initially underwent left bronchial artery embolisation for massive haemoptysis in the context of severe tuberculotic sequels. Under NIV and after heavy coughing he became hemiparetic and his level of consciousness suddenly dropped. Computed tomography of the brain showed multiple air embolism and ischaemic lesions were confirmed by magnetic resonance imaging. Echocardiographic investigations showed no intracardiac defect. Vasculo-pulmonary abnormalities in the context of heavy coughing and non-invasive ventilation may have played a major role in the occurrence of this event. New neurological events in a patient with tuberculotic sequels or any known vascular pulmonary abnormalities and NIV should raise the suspicion of brain gas embolism.

Clinical review: agitation and delirium in the critically ill--significance and management.

Agitation is a psychomotor disturbance characterized by a marked increase in motor and psychological activity in a patient. It occurs very frequently in the intensive care setting. It may be isolated, or accompanied by other mental disorders, such as severe anxiety and delirium. Frequently, agitation is a sign of brain dysfunction and, as such, may have adverse consequences, for at least two reasons. First, agitation can interfere with the patient's care and second, there is evidence demonstrating that the prognosis of agitated (and delirious) patients is worse than that of non-agitated (non-delirious) patients. These conditions are often under-diagnosed in the intensive care unit (ICU). Consequently, a systematic evaluation of this problem in ICU patients should be conducted. Excellent tools are presently available for this purpose. Treatment, including prevention, must be undertaken without delay, and the ICU physician should follow logical, strict and systematic rules when applying therapy.

The effect of workload on infection risk in critically ill patients.

OBJECTIVE: There is growing evidence that low nurse staffing jeopardizes quality of patient care. The objective of the study was to determine whether low staffing level increases the infection risk in critical care. DESIGN: Observational, single-center, prospective cohort study. SETTING: Medical intensive care unit of the University of Geneva Hospitals, Switzerland. PATIENTS: All patients admitted over a 4-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Study variables included all infections acquired in critical care, daily nurse-to-patient ratio, demographic characteristics, admission diagnosis and severity score, comorbidities, daily individual exposure to invasive devices, and selected drugs. Of a cohort of 1,883 patients totaling 10,637 patient-days, 415 (22%) developed at least one healthcare-associated infection while in critical care. Overall infection rate was 64.5 episodes per 1000 patient-days. Infected patients experienced higher mortality with a longer duration of stay both in critical care and in the hospital than noninfected patients (all p < .001). Median 24-hr nurse-to-patient ratio was 1.9. Controlling for exposure to central venous catheter, mechanical ventilation, urinary catheter, and antibiotics, we found that higher staffing level was associated with a >30% infection risk reduction (incidence rate ratio, 0.69; 95% confidence interval, 0.50-0.95). We estimated that 26.7% of all infections could be avoided if the nurse-to-patient ratio was maintained >2.2. CONCLUSIONS: Staffing is a key determinant of healthcare-associated infection in critically ill patients. Assuming causality, a substantial proportion of all infections could be avoided if nurse staffing were to be maintained at a higher level.

[Heliox in acute severe asthma]. / Emploi de mélanges hélium-oxygène (héliox) dans l'asthme aigu grave.

In acute severe asthma, the use of heliox can reduce dyspnea, when the patient is spontaneously breathing as well as in mechanical ventilation. This effect is due to a decrease in airway resistance. A better penetration of aerosolized bronchodilators has also been observed. However, the clinical benefit of these physiological measurable effects remains undetermined. Heliox could nevertheless be interesting in emergency situations in order to avoid endotracheal intubation, and in very difficult cases when mechanical ventilation is almost impossible to perform. This gas mixture could also be used with non-invasive mechanical ventilation, but this indication is presently investigated.

Clinical evaluation of hormonal stress state in medical ICU patients: a prospective blinded observational study.

OBJECTIVE: To evaluate whether classification of patients as having low, moderate, or high stress based on clinical parameters is associated with plasma levels of stress hormone. DESIGN AND SETTING: Prospective, blinded, observational study in an 18-bed medical ICU. PATIENTS: Eighty-eight consecutive patients. INTERVENTIONS: Patients were classified as low (n=28), moderate (n=33) or high stress (n=27) on days 0 and 3 of ICU stay, based on 1 point for each abnormal parameter: body temperature, heart rate, systemic arterial pressure, respiratory rate, physical agitation, presence of infection and catecholamine administration. The stress categories were: high: 4 points or more, moderate 2-3 points, low 1 point. Plasma growth hormone (GH), insulin-like growth factor 1 (IGF-1), insulin, glucagon, cortisol were measured on days 0 and 3. MEASUREMENTS AND RESULTS: Plasma cortisol and glucagon were significantly higher and IGF-1 lower in high vs. low stress patients on days 0 and 3. High stress patients were more likely to have high cortisol levels (odds ratio 5.8, confidence interval 1.8-18.9), high glucagon (8.7, 2.1-36.1), and low IGF-1 levels (5.9, 1.8-19.0) than low stress patients on day 0. Moderate stress patients were also more likely to have high cortisol and glucagon levels than low stress patients. Insulin and GH did not differ significantly. Results were similar for day 3. CONCLUSIONS: Moderate and severe stress was significantly associated with high catabolic (cortisol, glucagon) and low anabolic (IGF-1) hormone levels. The hormonal stress level in ICU patients can be estimated from simple clinical parameters during routine clinical evaluation.

National questionnaire survey on what influences doctors' decisions about admission to intensive care.

OBJECTIVE: To determine what influences doctors' decisions about admission of patients to intensive care. DESIGN: National questionnaire survey using eight clinical vignettes involving hypothetical patients. SETTING: Switzerland. PARTICIPANTS: 402 Swiss doctors specialising in intensive care. MAIN OUTCOME MEASURES: Rating of factors influencing decisions on admission and response to eight hypothetical clinical scenarios. RESULTS: Of 381 doctors agreeing to participate, 232 (61%) returned questionnaires. Most rated as important or very important the prognosis of the underlying disease (82%) and of the acute illness (81%) and the patients' wishes (71%). Few considered important the socioeconomic circumstances of the patient (2%), religious beliefs (3%), and emotional state (6%). In the vignettes, underlying disease (cancer versus non-cancerous disease) was not associated with admission to intensive care, but four other factors were: patients' wishes (odds ratio 3.0, 95% confidence interval 2.0 to 4.6), "upbeat" personality (2.9, 1.9 to 4.4), younger age (1.5, 1.1 to 2.2), and a greater number of beds available in intensive care (1.8, 1.2 to 2.5). CONCLUSIONS: Doctors' decisions to admit patients to intensive care are influenced by patients' wishes and ethically problematic non-medical factors such as a patient's personality or availability of beds. Patients with cancer are not discriminated against.

Nosocomial bloodstream infection and clinical sepsis.

Primary bloodstream infection (BSI) is a leading, preventable infectious complication in critically ill patients and has a negative impact on patients' outcome. Surveillance definitions for primary BSI distinguish those that are microbiologically documented from those that are not. The latter is known as clinical sepsis, but information on its epidemiologic importance is limited. We analyzed prospective on-site surveillance data of nosocomial infections in a medical intensive care unit. Of the 113 episodes of primary BSI, 33 (29%) were microbiologically documented. The overall BSI infection rate was 19.8 episodes per 1,000 central-line days (confidence interval [CI] 95%, 16.1 to 23.6); the rate fell to 5.8 (CI 3.8 to 7.8) when only microbiologically documented episodes were considered. Exposure to vascular devices was similar in patients with clinical sepsis and patients with microbiologically documented BSI. We conclude that laboratory-based surveillance alone will underestimate the incidence of primary BSI and thus jeopardize benchmarking.

Impact of ventilator-associated pneumonia on resource utilization and patient outcome.

OBJECTIVE: To assess the effect of ventilator-associated pneumonia on resource utilization, morbidity, and mortality. DESIGN: Retrospective matched cohort study based on prospectively collected data. SETTING: Medical intensive care unit of a university teaching hospital. PATIENTS: Case-patients were all patients receiving mechanical ventilation for 48 hours or more who experienced an episode of ventilator-associated pneumonia. Control-patients were matched for number of discharge diagnoses, duration of mechanical support before the onset of pneumonia among case-patients, age, admission diagnosis, gender, and study period. RESULTS: One hundred six cases of ventilator-associated pneumonia were identified in 452 patients receiving mechanical ventilation. The matching procedure selected 97 pairs. Length of stay in the intensive care unit and duration of mechanical ventilation were greater among case-patients by a mean of 7.2 days (P< .001) and 5.1 days (P< .001), respectively. Median costs were $24,727 (interquartile range, $18,348 to $39,703) among case-patients and $17,438 (interquartile range, $12,261 to $24,226) among control-patients (P < .001). The attributable mortality rate was 7.3% (P = .26). The attributable extra hospital stay was 10 days with an extra cost of $15,986 per episode of pneumonia. CONCLUSION: Ventilator-associated pneumonia negatively affects patient outcome and represents a significant burden on intensive care unit and hospital resources.