Explore the vast range of titles available.

Purpose Although rapid response systems are known to reduce in-hospital cardiac arrest rate, their effect on mortality remains debated. The present study aimed to evaluate the effect of implementing an intensivist-led rapid response team (RRT) on mortality in hospitalized patients. Methods An implementation of an intervention and a comparison with retrospective data analysis were performed in the four hospitals of Montpellier regional healthcare centre, in France. An intensivist-led RRT was implemented on a 24/7 basis along with educational modules, publicity and bedside simulation-based training in only one of the four hospitals from January 2012 to June 2012. A single activation criterion (heart rate below 40/min or above 140/min, systolic blood pressure below 80 mmHg, cardiac arrest, respiratory rate below 8/min or above 30/min, pulse oximetry below 90 % with O 2 above 6 l/min, respiratory distress in a tracheotomised patient, respiratory arrest, coma or sudden change in level of consciousness, seizure) allowed any caregiver to directly contact the RRT using a dedicated cell phone number. Patients over 18 years admitted for more than 24 h in the medical-surgical wards from July 2010 to December 2011 (pre-RRT period) and from July 2012 to December 2013 (RRT period) were included. The main outcome was unexpected mortality. Analyses of data from one RRT hospital and three control hospitals (no RRT hospital) were performed. Results RRT implementation was associated with a decrease in unexpected mortality rate in the hospital that implemented RRT (from 21.9 to 17.4 per 1000 discharges; p  = 0.002). Reduction in unexpected mortality associated with RRT implementation could be estimated at 1.5 lives saved per week in the RRT hospital. In the three other hospitals, mortality rate was not significantly modified (from 19.5 to 19.9 per 1000 discharges; p  = 0.69). Overall mortality decreased from 39.6 to 34.6 per 1000 discharges between the pre-RRT and RRT period in the RRT hospital ( p  = 0.012), but did not significantly change in the other hospitals. Patients in the RRT hospital were more frequently admitted to the intensive care unit (ICU) during the RRT period (45.8 vs 52.9 per 1000; p  = 0.002), and their sequential organ failure assessment (SOFA) score upon ICU admission significantly decreased from 7 (4–10) to 5 (2–9); p  < 0.001. Conclusions In the present retrospective study, implementation of an intensivist-led RRT along with educational modules, publicity and bedside simulation-based training was associated with a significant decrease in unexpected and overall mortality of inpatients.

PurposeThe relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status.MethodsWe conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index ≥ 30 kg/m2) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90.ResultsThree hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40–53) in the non-obese and 46% (95% CI, 36–56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9 ± 4.2 cmH2O) than in non-survivors (15.2 ± 5.2 cmH2O, p < 0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7 ± 4.5 cmH2O) and non-survivors (13.2 ± 5.1 cmH2O, p = 0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR = 1.04 (95% CI 1.01–1.07) for each point of increase], Crs [HR = 0.97 (95% CI 0.96–0.99) for each point of increase] and driving pressure [HR = 1.07 (95% CI 1.04–1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients.ConclusionsContrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.

Purpose High-flow nasal cannula oxygen (HFNC) has the potential to provide apnoeic oxygenation. We decided to assess in a proof-of-concept study whether the addition of HFNC to non-invasive ventilation (NIV) could reduce oxygen desaturation during intubation, compared with NIV alone for preoxygenation, in severely hypoxaemic intensive care unit (ICU) patients with respiratory failure. Methods We conducted a randomised, controlled, single-centre trial with assessor-blinded outcome assessment in patients admitted to the ICU. Hypoxaemic patients requiring orotracheal intubation for respiratory failure were randomised to receive preoxygenation using HFNC [flow = 60 L/min, fraction of inspired oxygen (FiO 2 ) = 100 %] combined with NIV (pressure support = 10 cmH 2 O, positive end-expiratory pressure = 5 cmH 2 O, FiO 2  = 100 %) in the intervention group or NIV alone in the reference group prior to intubation. The primary outcome was the lowest oxygen saturation (SpO 2 ) during the intubation procedure. Secondary outcomes were intubation-related complications and ICU mortality. Results Between July 2015 and February 2016, we randomly assigned 25 and 24 patients to the intervention and reference groups, respectively. In both groups the main reasons for respiratory failure were pneumonia and ARDS. During the intubation procedure, the lowest SpO 2 values were significantly higher in the intervention group than in the reference group [100 (95–100) % vs. 96 (92–99) %, p  = 0.029]. After exclusion of two patients from analysis for protocol violation, no (0 %) patients in the intervention group and five (21 %) patients in the reference group had SpO 2 below 80 % ( p  = 0.050). We recorded no significant difference between the groups in intubation-related complications or ICU mortality. Conclusions A novel strategy for preoxygenation in hypoxaemic patients, adding HFNC for apnoeic oxygenation to NIV prior to orotracheal intubation, may be more effective in reducing the severity of oxygen desaturation than the reference method using NIV alone.

Acute acidaemia is frequently observed during critical illness. Sodium bicarbonate infusion for the treatment of severe metabolic acidaemia is a possible treatment option but remains controversial, as no studies to date have examined its effect on clinical outcomes. Therefore, we aimed to evaluate whether sodium bicarbonate infusion would improve these outcomes in critically ill patients. We did a multicentre, open-label, randomised controlled, phase 3 trial. Local investigators screened eligible patients from 26 intensive care units (ICUs) in France. We included adult patients (aged ≥18 years) who were admitted within 48 h to the ICU with severe acidaemia (pH ≤7·20, PaCO2 ≤45 mm Hg, and sodium bicarbonate concentration ≤20 mmol/L) and with a total Sequential Organ Failure Assessment score of 4 or more or an arterial lactate concentration of 2 mmol/L or more. We randomly assigned patients (1:1), by stratified randomisation with minimisation via a restricted web platform, to receive either no sodium bicarbonate (control group) or 4·2% of intravenous sodium bicarbonate infusion (bicarbonate group) to maintain the arterial pH above 7·30. Our protocol recommended that the volume of each infusion should be within the range of 125–250 mL in 30 min, with a maximum of 1000 mL within 24 h after inclusion. Randomisation criteria were stratified among three prespecified strata: age, sepsis status, and the Acute Kidney Injury Network (AKIN) score. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7. All analyses were done on data from the intention-to-treat population, which included all patients who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02476253. Between May 5, 2015, and May 7, 2017, we enrolled 389 patients into the intention-to-treat analysis in the overall population (194 in the control group and 195 in the bicarbonate group). The primary outcome occurred in 138 (71%) of 194 patients in the control group and 128 (66%) of 195 in the bicarbonate group (absolute difference estimate −5·5%, 95% CI −15·2 to 4·2; p=0·24). The Kaplan-Meier method estimate of the probability of survival at day 28 between the control group and bicarbonate group was not significant (46% [95% CI 40–54] vs 55% [49–63]; p=0·09. In the prespecified AKIN stratum of patients with a score of 2 or 3, the Kaplan-Meier method estimate of survival by day 28 between the control group and bicarbonate group was significant (37% [95% CI 28–48] vs 54% [45–65]; p=0·0283). Metabolic alkalosis, hypernatraemia, and hypocalcaemia were observed more frequently in the bicarbonate group than in the control group, with no life-threatening complications reported. In patients with severe metabolic acidaemia, sodium bicarbonate had no effect on the primary composite outcome. However, sodium bicarbonate decreased the primary composite outcome and day 28 mortality in the a-priori defined stratum of patients with acute kidney injury. French Ministry of Health and the Société Française d'Anesthésie Réanimation.

Background Findings from preclinical studies and one pilot clinical trial suggest potential benefits of epidural analgesia in acute pancreatitis. We aimed to assess the efficacy of thoracic epidural analgesia, in addition to usual care, in improving clinical outcomes of intensive care unit patients with acute pancreatitis. Methods A multicenter, open-label, randomized, controlled trial including adult patients with a clinical diagnosis of acute pancreatitis upon admission to the intensive care unit. Participants were randomly assigned (1:1) to a strategy combining thoracic epidural analgesia and usual care (intervention group) or a strategy of usual care alone (control group). The primary outcome was the number of ventilator-free days from randomization until day 30. Results Between June 2014 and January 2019, 148 patients were enrolled, and 135 patients were included in the intention-to-treat analysis, with 65 patients randomly assigned to the intervention group and 70 to the control group. The number of ventilator-free days did not differ significantly between the intervention and control groups (median [interquartile range], 30 days [15–30] and 30 days [18–30], respectively; median absolute difference of − 0.0 days, 95% CI − 3.3 to 3.3; p  = 0.59). Epidural analgesia was significantly associated with longer duration of invasive ventilation (median [interquartile range], 14 days [5–28] versus 6 days [2–13], p  = 0.02). Conclusions In a population of intensive care unit adults with acute pancreatitis and low requirement for intubation, this first multicenter randomized trial did not show the hypothesized benefit of epidural analgesia in addition to usual care. Safety of epidural analgesia in this setting requires further investigation. Trial registration : ClinicalTrials.gov registration number NCT02126332 , April 30, 2014.

Background The administration of sedatives and analgesics in intensive care units (ICUs) has evolved significantly over the past 20 years, shifting from deep to light sedation strategies to minimize adverse effects. Despite this shift, substantial variability persists in sedation-analgesia practices. This study aimed to provide an updated national overview of sedation-analgesia management with a focus on discomfort assessment practices, including pain, delirium, anxiety, thirst, mood, and sleep disorders. Methods This was a one-day, multicenter, cross-sectional study conducted in French ICUs. Data were collected from all adult patients hospitalized in the ICU on the study day. A Unit-level survey documented ICU characteristics and sedation-analgesia protocols. Patient-level data included sedation levels, pain scores, and assessments of discomfort conditions. Statistical analyses were performed using descriptive methods and multilevel logistic regression. Results Among 258 French ICUs contacted, 128 units (50%) participated, enrolling 2,063 patients. Most ICUs were university-affiliated (54%) and mixed medical-surgical (58%); 63% had a written protocol for sedation-analgesia. Sedation and pain were assessed in 96% and 91% of ICUs, respectively. Light or no sedation was observed in 84% of patients, while 15% were deeply sedated – 63% of whom were misaligned with usual indications. Pain assessment was performed at rest in 90% of patients and during care in 62%. Pain prevalence increased with lighter sedation levels and during care. Hypnotics were used in 31% of patients, Mainly propofol and midazolam. Discomfort was reported in 44% of patients, mainly anxiety, sleep disorders, and thirst. Written protocols for sedation and analgesia were not associated with sedation depth, drug use, or delirium screening, but were linked to more frequent pain assessment at rest. Multivariable analyses showed that higher SOFA scores were associated with deep or misaligned deep sedation. The presence of a written protocol for sedation and analgesia reduced the risk of unassessed pain but was not associated with deep or misaligned deep sedation. Conclusion The shift toward lighter sedation has been successfully achieved; however, a broad spectrum of stressful symptoms persists, including pain, anxiety, thirst, and sleep disruption. These findings underscore the need for more effective strategies to optimize pain and overall patient comfort in non-deeply sedated ICU patients.

Findings from preclinical studies and one pilot clinical trial suggest potential benefits of epidural analgesia in acute pancreatitis. We aimed to assess the efficacy of thoracic epidural analgesia, in addition to usual care, in improving clinical outcomes of intensive care unit patients with acute pancreatitis. Methods A multicenter, open-label, randomized, controlled trial including adult patients with a clinical diagnosis of acute pancreatitis upon admission to the intensive care unit. Participants were randomly assigned (1:1) to a strategy combining thoracic epidural analgesia and usual care (intervention group) or a strategy of usual care alone (control group). The primary outcome was the number of ventilator-free days from randomization until day 30. Results Between June 2014 and January 2019, 148 patients were enrolled, and 135 patients were included in the intention-to-treat analysis, with 65 patients randomly assigned to the intervention group and 70 to the control group. The number of ventilator-free days did not differ significantly between the intervention and control groups (median [interquartile range], 30 days [15–30] and 30 days [18–30], respectively; median absolute difference of − 0.0 days, 95% CI − 3.3 to 3.3; p = 0.59). Epidural analgesia was significantly associated with longer duration of invasive ventilation (median [interquartile range], 14 days [5–28] versus 6 days [2–13], p = 0.02). Conclusions In a population of intensive care unit adults with acute pancreatitis and low requirement for intubation, this first multicenter randomized trial did not show the hypothesized benefit of epidural analgesia in addition to usual care. Safety of epidural analgesia in this setting requires further investigation. Trial registration : ClinicalTrials.gov registration number NCT02126332 , April 30, 2014.

Dans les Salons consacrés au peintre Hubert Robert, Diderot décrit ce qu’il appelle une “poétique des ruines.” Cette poétique est largement définie par la manière dont Diderot envisage la réponse esthétique du spectateur qui contemple les tableaux de Hubert Robert. Nous montrons que cette réponse esthétique est conçue comme un processus cognitif complexe, par lequel les spectateurs doivent devenir complices de la destruction représentée dans le tableau. Nous examinons comment Louis Sébastien Mercier, dans son Tableau de Paris , s’appuie sur ce modèle pour engager ses lecteurs dans une critique de l’absolutisme en France. In the Salons that discuss the painter Hubert Robert, Diderot describes what he calls a “poetics of ruins.” This poetics is largely defined by the way Diderot envisions the aesthetic response of the viewer who contemplates Robert’s paintings. We show that this aesthetic response is conceived as a complex cognitive process, through which the viewer becomes complicit in the destruction depicted in the painting. We examine how Louis Sébastien Mercier, in his Tableau de Paris , draws on this model to engage his reader in a critique of absolutism in France.

The use of matrix-assisted laser desorption ionization–time of flight (MALDI-TOF) mass spectrometry has proven to be rapid and accurate for the majority of clinical isolates. Some gaps remain concerning rare, emerging, or highly pathogenic species, showing the need to continuously expand the databases. In this multicenter study, we evaluated the accuracy of the VITEK MS v3.2 database in identifying 1172 unique isolates compared to identification by DNA sequence analysis. A total of 93.6% of the isolates were identified to species or group/complex level. A remaining 5.2% of the isolates were identified to the genus level. Forty tests gave a result of no identification (0.9%) and 12 tests (0.3%) gave a discordant identification compared to the reference identification. VITEK MS is also the first MALDI-TOF MS system that is able to delineate the four members of the Acinetobacter baumannii complex at species level without any specific protocol or special analysis method. These findings demonstrate that the VITEK MS v3.2 database is highly accurate for the identification of bacteria and fungi encountered in the clinical laboratory as well as emerging species like Candida auris and the highly pathogenic Brucella species.