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Background Circadian clock alterations were poorly reported in trauma patients, although they have a critical role in human physiology. Core body temperature is a clinical variable regulated by the circadian clock. Our objective was to identify the circadian temperature disruption in trauma patients and to determine whether these disruptions were associated with the 28-day mortality rate. Methods A retrospective and observational single-center cohort study was conducted. All adult severe trauma patients admitted to the intensive care unit of Aix Marseille University, North Hospital, from November 2013 to February 2018, were evaluated. The variations of core body temperature for each patient were analyzed between days 2 and 3 after intensive care unit admission. Core body temperature variations were defined by three parameters: mesor, amplitude, and period. A logistic regression model was used to determine the variables influencing these three parameters. A survival analysis was performed assessing the association between core body temperature rhythm disruption and 28-day mortality rate. A post hoc subgroup analysis focused on the patients with head trauma. Results Among the 1584 screened patients, 248 were included in this study. The period differed from 24 h in 177 (71%) patients. The mesor value (°C) was associated with body mass index and ketamine use. Amplitude (°C) was associated with ketamine use only. The 28-day mortality rate was 18%. For all trauma patients, age, body mass index, intracranial hypertension, and amplitude were independent risk factors. The patients with a mesor value < 36.9 °C ( p  < 0.001) and an amplitude > 0.6 °C ( p  < 0.001) had a higher 28-day mortality rate. Among the patients with head trauma, mesor and amplitude were identified as independent risk factors (HR = 0.40, 95% CI [0.23–0.70], p  = 0.001 and HR = 4.73, 95% CI [1.38–16.22], p  = 0.01). Conclusions Our results highlight an association between core body temperature circadian alteration and 28-day mortality rate. This association was more pronounced in the head trauma patients than in the non-head trauma patients. Further studies are needed to show a causal link and consider possible interventions.

Background: Procalcitonin (PCT) protocols to guide antibiotic treatment for ventilator-associated pneumonia (VAP) in the intensive care unit aim at reducing antibiotic exposure. Our study goal was to measure compliance with a PCT protocol for VAP and to determine the associated variables. Methods: From 2017 to 2021, we conducted a retrospective, monocentric study including patients treated for VAP. In our PCT protocol, PCT was measured at the initiation of antibiotic treatment and every 48 h until treatment completion; antibiotics were stopped if PCT decreased by more than 80% from its highest value or fell below 0.5 ng/mL. We assessed the compliance with the PCT protocol and compared the compliant and noncompliant groups. Results: Among the 177 included patients, compliance with the PCT protocol was assessed at 58%. Noncompliance was due to lack of PCT measurements in 76% of cases. Compliance was higher in the medical patients (p = 0.04) and in those admitted for SARS-CoV-2 (p = 0.02). Compliance regarding the interruption of antibiotic therapy based on PCT was lower on weekends and holidays (p = 0.01). Outcomes did not differ according to compliance. Conclusion: This study assessed real-life compliance with the PCT protocol to monitor antibiotic treatment for VAP. Improving the measurement of PCT at the bedside would increase the rate.

Purpose We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. Methods Prospective nationwide before–after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013–31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6–8 cm H 2 O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. Results A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0–80) vs. 67 (0–80) days; P  = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention ( P  < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66–82) and 71 (0–80) days, respectively; P  = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group ( P  = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41–2.26; P  < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56–3.26, P  < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation. Conclusions Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number : NCT01885507.

Objective To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU). Background POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown. Methods Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified. Results Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts. Conclusions With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.

Data on the relationship between antimicrobial resistance and mortality remain scarce, and this relationship needs to be investigated in intensive care units (ICUs). The aim of this study was to compare the ICU mortality rates between patients with ICU-acquired pneumonia due to highly antimicrobial-resistant (HAMR) bacteria and those with ICU-acquired pneumonia due to non-HAMR bacteria. We conducted a multicenter, retrospective cohort study using the French National Surveillance Network for Healthcare Associated Infection in ICUs (“REA-Raisin”) database, gathering data from 200 ICUs from January 2007 to December 2016. We assessed all adult patients who were hospitalized for at least 48 h and presented with ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii . The association between pneumonia caused by HAMR bacteria and ICU mortality was analyzed using the whole sample and using a 1:2 matched sample. Among the 18,497 patients with at least one documented case of ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii , 3081 (16.4%) had HAMR bacteria. The HAMR group was associated with increased ICU mortality (40.3% vs. 30%, odds ratio (OR) 95%, CI 1.57 [1.45–1.70], P  < 0.001). This association was confirmed in the matched sample (3006 HAMR and 5640 non-HAMR, OR 95%, CI 1.39 [1.27–1.52], P  < 0.001) and after adjusting for confounding factors (OR ranged from 1.34 to 1.39, all P  < 0.001). Our findings suggest that ICU-acquired pneumonia due to HAMR bacteria is associated with an increased ICU mortality rate, ICU length of stay, and mechanical ventilation duration.

This study aimed to describe by mathematical modeling an accurate course of core body temperature (CBT) in severe trauma patients and its relation to sepsis. In a cohort of severe trauma, the CBT measurements were collected for 24 h on day 2 after admission and rhythmicity assessed by Fourier transform and Cosinor analysis to describe circadian features (frequency and amplitude). CBT was compared between patients who developed sepsis or not during the early ICU stay. 33 patients were included in this analysis. 24 patients (73%) had a predominant rhythm of 24 h (period). The main period was lower in the 9 remaining patients (6 of 12 h, 1 of 8 h, and 2 of 6 h). Other significant frequencies of oscillation (second and third frequencies) were found, which showed an association of several well-marked rhythms. Patients with sepsis (n = 12) had a significantly higher level of CBT, but also more intense rhythms and higher amplitudes of CBT. Trauma patients exhibit complex temperature circadian rhythms. Early exacerbation of the temperature rhythmicity (in frequency and amplitude) is associated with the development of sepsis. This observation accentuates the concept of circadian disruption and sepsis in ICU patients. [Display omitted]

Selective digestive decontamination (SDD) reduces the rate of infection and improves the outcomes of patients admitted to an intensive care unit (ICU). A risk associated with its use is the development of multi-drug-resistant organisms. We hypothesized that a 1-day reduction in systemic antimicrobial exposure in the SDD regimen would not affect the outcomes of our patients. In this before-and-after study design, 199 patients and 248 patients were included in a 3-day SDD group and a 2-day SDD group, respectively. The rates of hospital-acquired pneumonia and ICU infections were similar in both groups. The rates of bloodstream infection and bacteriuria were significantly lower in the 2-day SDD group than in the 3-day SDD group. Compared with the patients in the 3-day group, the patients in the 2-day SDD group received fewer antibiotics and less exposure to mechanical ventilation, and they used fewer ICU resources. The rates of ICU mortality and 28-day mortality were similar in both groups. The incidence of multi-drug-resistant organisms was similar in both groups. Within the limitations inherent to our study design, reducing the exposure of prophylactic systemic antibiotics in the SDD setting from 3 days to 2 days was not associated with impaired outcomes. Future randomized controlled trials should be conducted to test this hypothesis and investigate the effects on the development of multi-drug resistant organisms.

Importance Decision-making in trauma patients remains challenging and often results in deviation from guidelines. Machine-Learning (ML) enhanced decision-support could improve hemorrhage resuscitation. Aim To develop a ML enhanced decision support tool to predict Need for Hemorrhage Resuscitation (NHR) (part I) and test the collection of the predictor variables in real time in a smartphone app (part II). Design, setting, and participants Development of a ML model from a registry to predict NHR relying exclusively on prehospital predictors. Several models and imputation techniques were tested. Assess the feasibility to collect the predictors of the model in a customized smartphone app during prealert and generate a prediction in four level-1 trauma centers to compare the predictions to the gestalt of the trauma leader. Main outcomes and measures Part 1: Model output was NHR defined by 1) at least one RBC transfusion in resuscitation, 2) transfusion ≥ 4 RBC within 6 h, 3) any hemorrhage control procedure within 6 h or 4) death from hemorrhage within 24 h. The performance metric was the F4-score and compared to reference scores ( RED FLAG, ABC ). In part 2, the model and clinician prediction were compared with Likelihood Ratios (LR). Results From 36,325 eligible patients in the registry (Nov 2010—May 2022), 28,614 were included in the model development (Part 1). Median age was 36 [25–52], median ISS 13 [5–22], 3249/28614 (11%) corresponded to the definition of NHR . A XGBoost model with nine prehospital variables generated the best predictive performance for NHR according to the F4-score with a score of 0.76 [0.73–0.78]. Over a 3-month period (Aug—Oct 2022), 139 of 391 eligible patients were included in part II (38.5%), 22/139 with NHR . Clinician satisfaction was high, no workflow disruption observed and LRs comparable between the model and the clinicians. Conclusions and relevance The ShockMatrix pilot study developed a simple ML-enhanced NHR prediction tool demonstrating a comparable performance to clinical reference scores and clinicians. Collecting the predictor variables in real-time on prealert was feasible and caused no workflow disruption.

Our study aimed to explore the association between early hyperoxemia of the first 24 h on outcomes in patients with severe blunt chest trauma. In a level I trauma center, we conducted a retrospective study of 426 consecutive patients. Hyperoxemic groups were classified in severe (average PaO2 ≥ 200 mmHg), moderate (≥150 and < 200 mmHg) or mild (≥ 100 and < 200 mmHg) and compared to control group (≥60 and < 100 mmHg) using a propensity score based analysis. The first endpoint was the incidence of a composite outcome including death and hospital-acquired pneumonia occurring from admission to day 28. The secondary endpoints were the incidence of death, the number of hospital-acquired pneumonia, mechanical ventilation-free days and intensive care unit-free day at day 28. The incidence of the composite endpoint was lower in the severe hyperoxemia group(OR, 0.25; 95%CI, 0.09–0.73; P < 0.001) compared with control. The 28-day mortality incidence was lower in severe (OR, 0.23; 95%CI, 0.08–0.68; P < 0.001) hyperoxemia group (OR, 0.41; 95%CI, 0.17–0.97; P = 0.04). Significant association was found between hyperoxemia and secondary outcomes. In our cohort early hyperoxemia during the first 24 h of admission after severe blunt chest trauma was not associated with worse outcome. •Effect of hyperoxia remains unexplored in blunt chest trauma•Early hyperoxia may have an anti-bacterial and anti-inflammatory effect•Early hyperoxia is associated with lower incidence of pneumonia after chest trauma•Severe blunt chest trauma may benefit of early hyperoxia

Purpose Prone position (PP) improves oxygenation and outcome of acute respiratory distress syndrome (ARDS) patients with a PaO 2 /FiO 2 ratio <150 mmHg. Regional changes in lung aeration can be assessed by lung ultrasound (LUS). Our aim was to predict the magnitude of oxygenation response after PP using bedside LUS. Methods We conducted a prospective multicenter study that included adult patients with severe and moderate ARDS. LUS data were collected at four time points: 1 h before (baseline) and 1 h after turning the patient to PP, 1 h before and 1 h after turning the patient back to the supine position. Regional lung aeration changes and ultrasound reaeration scores were assessed at each time. Overdistension was not assessed. Results Fifty-one patients were included. Oxygenation response after PP was not correlated with a specific LUS pattern. The patients with focal and non-focal ARDS showed no difference in global reaeration score. With regard to the entire PP session, the patients with non-focal ARDS had an improved aeration gain in the anterior areas. Oxygenation response was not associated with aeration changes. No difference in PaCO 2 change was found according to oxygenation response or lung morphology. Conclusions In ARDS patients with a PaO 2 /FiO 2 ratio ≤150 mmHg, bedside LUS cannot predict oxygenation response after the first PP session. At the bedside, LUS enables monitoring of aeration changes during PP.