Feasibility and safety of ultra-low tidal volume ventilation without extracorporeal circulation in moderately severe and severe ARDS patients.

PURPOSE: Mechanical ventilation with ultra-low tidal volume (VT) during ARDS may reduce alveolar strain, driving pressure and hence ventilator-induced lung injury, with the main drawback of worsening respiratory acidosis. We hypothesized that VT could be reduced down to 4 ml/kg, with clinically significant decrease in driving pressure, without the need for extracorporeal CO2 removal, while maintaining pH > 7.20. METHODS: We conducted a non-experimental before-and-after multicenter study on 35 ARDS patients with PaO2/FiO2 ≤ 150 mmHg, within 24 h of ARDS diagnosis. After inclusion, VT was reduced to 4 ml/kg and further adjusted to maintain pH ≥ 7.20, respiratory rate was increased up to 40 min-1 and PEEP was set using a PEEP-FiO2 table. The primary judgment criterion was driving pressure on day 2 of the study, as compared to inclusion. RESULTS: From inclusion to day 2, driving pressure decreased significantly from 12 [9-15]  to 8 [6-11] cmH2O, while VT decreased from 6.0 [5.9-6.1] to 4.1 [4.0-4.7] ml/kg. On day 2, VT was below 4.2 ml/kg in 65% [CI95% 48%-79%], and below 5.25 ml/kg in 88% [CI95% 74%-95%] of the patients. 2 patients (6%) developed acute cor pulmonale after inclusion. Eleven patients (32%) developed transient severe acidosis with pH < 7.15. Fourteen patients (41%) died before day 90. CONCLUSION: Ultra-low tidal volume ventilation may be applied in approximately 2/3 of moderately severe-to-severe ARDS patients, with a 4 cmH2O median reduction in driving pressure, at the price of transient episodes of severe acidosis in approximately 1/3 of the patients.

Prognostic significance of central venous-to-arterial carbon dioxide difference during the first 24 hours of septic shock in patients with and without impaired cardiac function.

OBJECTIVE: To investigate the prognostic significance of central venous-to-arterial carbon dioxide difference (cv-art CO 2 gap) during septic shock in patients with and without impaired cardiac function. METHODS: We performed a prospective cohort study in 10 French intensive care units. Patients suffering from septic shock were assigned to the impaired cardiac function group ('cardiac group', n =123) if they had atrial fibrillation (AF) and/or left ventricular ejection fraction (LVEF) <50% at study entry and to the non-cardiac group ( n =240) otherwise. RESULTS: Central venous and arterial blood gases were sampled every 6 h during the first 24 h to calculate cv-art CO 2 gap. Patients in the cardiac group had a higher cv-art CO 2 gap [at study entry and 6 and 12 h (all P <0.02)] than the non-cardiac group. Patients in the cardiac group with a cv-art CO 2 gap >0.9 kPa at 12 h had a higher risk of day 28 mortality (hazard ratio=3.18; P =0.0049). Among the 59 patients in the cardiac group with mean arterial pressure (MAP) ≥65 mm Hg, central venous pressure (CVP) ≥8 mm Hg and central venous oxygen saturation (ScvO 2 ) ≥70% at 12 h, those with a high cv-art CO 2 gap (>0.9 kPa; n =19) had a higher day 28 mortality (37% vs. 13%; P =0.042). In the non-cardiac group, a high cv-art CO 2 gap was not linked to a higher risk of day 28 death, whatever the threshold value of the cv-art CO 2 gap. CONCLUSION: Patients with septic shock and with AF and/or low LVEF were more prone to a persistent high cv-art CO 2 gap, even when initial resuscitation succeeded in normalizing MAP, CVP, and ScvO 2 . In these patients, a persistent high cv-art CO 2 gap at 12 h was significantly associated with higher day 28 mortality.

Significance of soluble triggering receptor expressed on myeloid cells-1 elevation in patients admitted to the intensive care unit with sepsis.

BACKGROUND: Among septic patients admitted to the intensive care unit (ICU), early recognition of those with the highest risk of death is of paramount importance. Since clinical judgment is sometimes uncertain biomarkers could provide additional information likely to guide critical illness management. We evaluated the prognostic value of soluble Triggering Receptor Expressed by Myeloid cells 1 (sTREM-1), procalcitonin (PCT) and leucocyte surface expression of CD64. METHODS: This was a prospective cohort study, which included 190 septic patient admitted to the ICU in two hospitals. Blood samples for biomarker measurements were obtained upon admission and thereafter. The Simplified Acute Physiology Score (SAPS) II and the Sequential Organ Failure Assessment (SOFA) score were calculated. The primary outcome was all-cause death in the ICU. RESULTS: The mortality rate reached 25.8 %. The best predictive value of the three biomarkers was obtained with baseline sTREM-1, although clinical scores outperformed this. Accuracy was greater in patients without prior exposure to antibiotics and in those with proven bacterial infection. Adding sTREM-1 levels to SAPS II increased its specificity to 98 %. The soluble TREM-1 level, core temperature and SAPS II value were the only independent predictors of death after adjustment for potential confounders. A decrease in sTREM-1 with time was also more pronounced in survivors than in non-survivors. CONCLUSIONS: sTREM-1 was found to be the best prognostic biomarker among those tested. Both baseline values and variations with time seemed relevant. Although SAPS II outperformed sTREM-1 regarding the prediction of ICU survival, the biomarker could provide additional information.

Impact of an intensive communication strategy on end-of-life practices in the intensive care unit.

PURPOSE: Since the 2005 French law on end of life and patients' rights, it is unclear whether practices have evolved. We investigated whether an intensive communication strategy based on this law would influence practices in terms of withholding and withdrawing treatment (WWT), and outcome of patients hospitalised in intensive care (ICU). METHODS: This was a single-centre, two-period study performed before and after the 2005 law. Between these periods, an intensive strategy for communication was developed and implemented, comprising regular meetings and modalities for WWT. We examined medical records of all patients who died in the ICU or in hospital during both periods. RESULTS: In total, out of 2,478 patients admitted in period 1, 678 (27%) died in the ICU and 823/2,940 (28%) in period 2. In period 1, among patients who died in the ICU, 45% died subsequent to a decision to WWT versus 85% in period 2 (p < 0.01). Among these, median time delay between ICU admission and initiation of decision-making process was significantly different (6-7 days in period 1 vs. 3-5 days in period 2, p < 0.05). Similarly, median time from admission to actual WWT decision was significantly shorter in period 2 (11-13 days in period 1 vs. 4-6 days in period 2, p < 0.05). Finally, median time from admission to death in the ICU subsequent to a decision to WWT was 13-15 days in period 1 versus 7-8 days in period 2, p < 0.05. Reasons for WWT were not significantly different between periods. CONCLUSION: Intensive communication brings about quicker end-of-life decision-making in the ICU. The new law has the advantage of providing a legal framework.

Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.

PURPOSE: Burnout syndrome (BOS) has frequently been reported in healthcare workers, and precipitating factors include communication problems in the workplace and stress related to end-of-life situations. We evaluated the effect of an intensive communication strategy on BOS among caregivers working in intensive care (ICU). METHODS: Longitudinal, monocentric, before-and-after, interventional study. BOS was evaluated using the Maslach Burnout Inventory (MBI) and depression using the Centre for Epidemiologic Studies Depression Scale (CES-D) in 2007 (period 1) and 2009 (period 2). Between periods, an intensive communication strategy on end-of-life practices was implemented, based on improved organisation, better communication, and regular staff meetings. RESULTS: Among 62 caregivers in the ICU, 53 (85%) responded to both questionnaires in period 1 and 49 (79%) in period 2. We observed a significant difference between periods in all three components of the MBI (emotional exhaustion, p = 0.04; depersonalization p = 0.04; personal accomplishment, p = 0.01). MBI classified burnout as severe in 15 (28%) caregivers in period 1 versus 7 (14%) in period 2, p < 0.01, corresponding to a 50% risk reduction. Symptoms of depression as evaluated by the CES-D were present in 9 (17%) caregivers in period 1 versus 3 (6%) in period 2, p < 0.05, corresponding to a risk reduction of almost 60%. CONCLUSION: The implementation of an active, intensive communication strategy regarding end-of-life care in the ICU was associated with a significant reduction in the rate of burnout syndrome and depression in a stable population of caregiving staff.

[Psychological experience of health care professionals in intensive care unit: a qualitative and exploratory study]. / Vécu psychologique des soignants en réanimation : une étude exploratoire et qualitative.

OBJECTIVES: Study the subjective and emotional experience of health care professionals in intensive care unit in front of sources of professional stress connected to the emergency and to the gravity of the pathologies of hospitalized patients. PATIENTS AND METHODS: A clinical interview was proposed to health care professionals of an intensive care unit during which they had to develop their personal feeling about the organization of the work and their management of the most stressful emotional situations. All interviews were entirely recorded and rewritten. Then, they were the object of a procedure of coding and a thematic analysis was detailed with the consensus of several individuals. RESULTS: Eighteen professionals agreed to participate in this research. The analysis of these clinical interviews showed a strong feeling of pressure in works as being mainly focused on the necessity of control the procedures and the technical means involved in intensive care unit and in the strong emotional load due to deaths of patients and to the pain of families. The management of the death and its conditions appears as a major and central difficulty. CONCLUSION: The discussion approaches the question of the feeling of pressure at works and its various items by underlining the interpersonal variations of these experiences, then the question of the emotional adaptation through the individual and collective defensive strategies organized to cope with these various situations.

Post mortem scientific sampling and the search for causes of death in intensive care: what information should be given and what consent should be obtained?

PURPOSE: The search for cause of death is important to improve knowledge and provide answers for the relatives of the deceased. Medical autopsy following unexplained death in hospital is one way to identify cause of death but is difficult to carry out routinely. Post mortem sampling (PMS) of tissues via thin biopsy needle or 'mini incisions' in the skin may be a useful alternative. A study was undertaken to assess how this approach is perceived by intensive care doctors and also to evaluate how this practice is considered in ethical terms in France. METHODS: A study of PMS practices immediately after death in 10 intensive care departments was performed. The medical director of each centre was interviewed by telephone and asked to describe practices in their unit and to outline the questions raised by this practice. RESULTS: PMS is routinely performed in 70% of the units which responded, without systematically obtaining formal consent and without precise rules for communicating results. Approaches to PMS differed between centres, but all physicians felt that PMS is useful for the scientific information it gives and also for the information it provides for relatives. All physicians regret the lack of standards to structure PMS practices. CONCLUSION: Information from post mortem examinations is important for society to inform about causes of death, for doctors to improve practices and for decision-makers responsible for organising care. Debate persists regarding the balance between individual rights and community interests. It is suggested that an approach for identifying cause of death could easily be integrated into the relationship between carers and relatives, provided full transparency is maintained.

[Magnetic resonance imaging of dilatation of the ascending aorta after repair of coarctation of the aorta]. / Etude de la dilatation de l'aorte ascendante par résonance magnétique nucléaire après réparation de la coarctation de l'aorte.

The authors studied the risk factors for dilatation of the ascending aorta in patients operated for coarctation of the aorta. A prospective study of the diameters of the ascending aorta by magnetic resonance imaging was undertaken in 46 patients with an average age of 30 months (range 6 days to 11 years) at surgery, and 10 years of age (6 months to 31 years) at the time of the investigation. The diameters were measured at the level of the sinus of Valsalva, at the sino-tubular junction, and compared with reference tables with respect to body surface area. Twenty six per cent of patients had dilatation of the ascending aorta. The predisposing factors were investigated. Age, type of surgery, postoperative hypertension. Doppler gradient in the isthmic region, anatomical appearances of the repair observed by MRI were not predictive of this complication. On the other hand, age of patients at MRI and bicuspid aortic valves (present in 66% of cases) (p < 0.05) were significant risk factors. These results indicate that regular follow-up by echocardiography or MRI of the diameter of the ascending aorta is necessary in patients operated for coarctation of the aorta and with bicuspid aortic valves.