Publications by authors named "Bernard Floccard"

43 Publications

Risk factors and events in the adult intensive care unit associated with pain as self-reported at the end of the intensive care unit stay.

Crit Care 2020 12 7;24(1):685. Epub 2020 Dec 7.

Unité de recherche EA3279, Aix-Marseille Université, Marseille, France.

Background: The short-term and long-term consequences of the most frequent painful procedures performed in the ICU are unclear. This study aimed to identify the risk factors associated with pain-related discomfort perceived by critically ill patients during the whole ICU stay as self-reported by patients at the end of their ICU stay.

Methods: The study involved 34 ICUs. Adult patients who survived an ICU stay of 3 calendar days or more were eligible for inclusion. Discomforts, including the pain-related discomfort, were assessed using the French 18-item questionnaire on discomfort in ICU patients, the "Inconforts des Patients de REAnimation" (IPREA). Patients scored each item from 0 (minimal discomfort) to 10 (maximal discomfort). Associations between patient characteristics at ICU admission, life support therapies and main potentially painful procedures performed during the ICU stay and pain-related discomfort scores assessed at the end of the ICU stay were analyzed.

Results: Patients with complete IPREA questionnaires (n = 2130) were included. The median pain-related discomfort score was 3 (IQR 0-5). From the univariate analysis, pain-related discomfort scores were negatively correlated with age and positively correlated with ICU stay duration; surgical patients reported significant higher pain-related discomfort scores than medical patients; chest drain insertion, chest drain removal, use of bladder catheter, central venous catheter (CVC) insertion, complex dressing change, and intra-hospital transport were associated with pain-related discomfort scores. From the multivariate analyses using generalized estimating equations models, only age, chest drain removal, use of a bladder catheter, CVC insertion, and intra-hospital transport were the main risk factors associated with pain-related discomfort scores.

Conclusion: Patients who underwent chest drain removal, bladder catheter, CVC insertion, and intra-hospital transport during their ICU stay reported higher pain-related discomfort scores (with respect to the whole ICU stay and assessed at the end of their ICU stay) than patients who did not experience these events. This study may pave the way for further targeted studies aiming at investigating a causal link between these common procedures in the ICU and adult critically ill patients' perceptions of their ICU stay regarding recalled pain.

Trial Registration: Clinicaltrials.gov Identifier NCT02442934, retrospectively registered on May 13, 2015.
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http://dx.doi.org/10.1186/s13054-020-03396-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722444PMC
December 2020

Early Detection of Patients at Risk of Developing a Post-Traumatic Stress Disorder After an ICU Stay.

Crit Care Med 2020 11;48(11):1572-1579

Hospices Civils de Lyon, Hôpital Edouard Herriot, Service des Urgences Psychiatriques, Lyon, France.

Objectives: To evaluate the diagnostic accuracy of the Impact Event Scale-Revisited assessed following ICU discharge to predict the emergence of post-traumatic stress disorder symptoms at 3 months.

Design: Prospective cohort study.

Setting: Three medical or surgical ICU of a French university hospital (Lyon, France).

Patients: Patients greater than or equal to 18 years old, leaving ICU after greater than or equal to 2 nights of stay, between September 2017 and April 2018.

Interventions: Patients completed the Impact Event Scale-Revisited and the Peritraumatic Dissociative Experiences Questionnaire within 8 days after ICU discharge and the Impact Event Scale-Revisited again at 3 months by phone. Patients having an Impact Event Scale-Revisited greater than or equal to 35 at 3 months were considered as having post-traumatic stress disorder symptoms.

Measurements And Main Results: Among the 208 patients screened, 174 were included and 145 reassessed by phone at 3 months. Among the patients included at baseline, 43% presented symptoms of acute stress. At 3 months, 13% had an Impact Event Scale-Revisited greater than or equal to 35 and 17% had a score between 12 and 34. Regarding the performance of the Impact Event Scale-Revisited performed within 8 days after the ICU discharge to predict post-traumatic stress disorder symptoms at 3 months, the area under the curve was 0.90 (95% CI, 0.80-0.99), and an Impact Event Scale-Revisited greater than or equal to 12 had a sensitivity of 90%, a specificity of 71%, a positive predictive value of 32%, and a negative predictive value of 98%. History of anxiety disorder odds ratio = 3.7 (95% CI, 1.24-11.05; p = 0.02) and Impact Event Scale-Revisited greater than or equal to 12 odds ratio = 16.57 (95% CI, 3.59-76.46; p < 0.001) were identified as risk factors for post-traumatic stress disorder symptoms.

Conclusions: Impact Event Scale-Revisited assessed at ICU discharge has a good ability for the detection of patients at risk of developing post-traumatic stress disorder symptoms. Patients with history of anxiety disorder and those presenting acute stress symptoms at ICU discharge are more at risk to develop post-traumatic stress disorder symptoms.
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http://dx.doi.org/10.1097/CCM.0000000000004551DOI Listing
November 2020

Effect of an ICU Diary on Posttraumatic Stress Disorder Symptoms Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial.

JAMA 2019 07;322(3):229-239

Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM, Paris Diderot University, Department of Biostatistics - HUPNVS. - AP-HP, UFR de Médecine - Bichat University Hospital, Paris, France.

Importance: Keeping a diary for patients while they are in the intensive care unit (ICU) might reduce their posttraumatic stress disorder (PTSD) symptoms.

Objectives: To assess the effect of an ICU diary on the psychological consequences of an ICU hospitalization.

Design, Setting, And Participants: Assessor-blinded, multicenter, randomized clinical trial in 35 French ICUs from October 2015 to January 2017, with follow-up until July 2017. Among 2631 approached patients, 709 adult patients (with 1 family member each) who received mechanical ventilation within 48 hours after ICU admission for at least 2 days were eligible, 657 were randomized, and 339 were assessed 3 months after ICU discharge.

Interventions: Patients in the intervention group (n = 355) had an ICU diary filled in by clinicians and family members. Patients in the control group (n = 354) had usual ICU care without an ICU diary.

Main Outcomes And Measures: The primary outcome was significant PTSD symptoms, defined as an Impact Event Scale-Revised (IES-R) score greater than 22 (range, 0-88; a higher score indicates more severe symptoms), measured in patients 3 months after ICU discharge. Secondary outcomes, also measured at 3 months and compared between groups, included significant PTSD symptoms in family members; significant anxiety and depression symptoms in patients and family members, based on a Hospital Anxiety and Depression Scale score greater than 8 for each subscale (range, 0-42; higher scores indicate more severe symptoms; minimal clinically important difference, 2.5); and patient memories of the ICU stay, reported with the ICU memory tool.

Results: Among 657 patients who were randomized (median [interquartile range] age, 62 [51-70] years; 126 women [37.2%]), 339 (51.6%) completed the trial. At 3 months, significant PTSD symptoms were reported by 49 of 164 patients (29.9%) in the intervention group vs 60 of 175 (34.3%) in the control group (risk difference, -4% [95% CI, -15% to 6%]; P = .39). The median (interquartile range) IES-R score was 12 (5-25) in the intervention group vs 13 (6-27) in the control group (difference, -1.47 [95% CI, -1.93 to 4.87]; P = .38). There were no significant differences in any of the 6 prespecified comparative secondary outcomes.

Conclusions And Relevance: Among patients who received mechanical ventilation in the ICU, the use of an ICU diary filled in by clinicians and family members did not significantly reduce the number of patients who reported significant PTSD symptoms at 3 months. These findings do not support the use of ICU diaries for preventing PTSD symptoms.

Trial Registration: ClinicalTrials.gov Identifier: NCT02519725.
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http://dx.doi.org/10.1001/jama.2019.9058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635906PMC
July 2019

Hereditary angioedema, emergency management of attacks by a call center.

Eur J Intern Med 2019 Sep 18;67:42-46. Epub 2019 May 18.

AP-HP, Urgences - Samu 93, Hôpital Avicenne, Université Paris 13, Inserm U942, 93000 Bobigny, France. Electronic address:

Objective: Hereditary angiœdema (HAE) is a rare autosomal dominant disease characterized by recurrent, unpredictable, potentially life-threatening swelling. Objective is to assess the management of the acute HAE attacks in the real life setting through a call center in France.

Methods: A pre-specified ancillary study of SOS-HAE, a cluster-randomized prospective multicenter trial, was conducted. HAE patients were recruited from 8 participating reference centers. The outcome of interest was the rate of hospitalization.

Results: onerhundred patients were included. The median (quartile) age was 38 (29-53) years, and 66 (66%) were female. Eighty (80%) patients had HAE type I, 8 (8%) had HAE type II and 12 (12%) patients had FXII-HAE. Fifty-one (51%) patients had experienced at least one time the call center during the follow-up. Nine over 166 (5%) attacks for 9 different patients resulted in hospital admission to the hospital (in the short-stay unit, ie, <24 h) during the follow-up period. During 2 years, there were 166 calls to call center for 166 attacks. All attacks were treated at home after call center contact.

Conclusions: Use of emergency departments and hospitalizations are reduced by the use of a coordinated national call center in HAE after therapeutic education program that promoted self-administration of specific treatment and use of call to call center.

Trial Registration: clinicalTrials.gov identifier: NCT01679912.
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http://dx.doi.org/10.1016/j.ejim.2019.05.007DOI Listing
September 2019

Assessment of patients' self-perceived intensive care unit discomforts: Validation of the 18-item version of the IPREA.

Health Qual Life Outcomes 2019 Feb 7;17(1):29. Epub 2019 Feb 7.

Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, Le Coudray, France.

Background And Aims: We reported the validation of the 18-item version of the 'Inconforts des Patients de REAnimation (IPREA)' questionnaire that includes 2 new items exploring feeling depressed and shortness of breath during an intensive care unit (ICU) stay.

Methods: The validation process was integrated in a multicenter, cluster-randomized, controlled, two-parallel group study built to assess the effectiveness of a tailored multicomponent program for reducing self-perceived discomfort in the ICU. All patients aged 18 years or older who survived an ICU stay of 3 calendar days or more were eligible for inclusion. Data collection included demographics (sex, age), type of admission (medical and surgical), health status scores at admission (Knaus score and McCabe index, Simplified Acute Physiology Score (SAPS) II), specific ICU therapeutics such as mechanical ventilation (MV), noninvasive ventilation (NIV), use of vasopressors, or renal replacement therapy (RRT), and ICU stay duration.

Results: A total of 994 patients were included. The initial structure of IPREA was confirmed using confirmatory factor analysis showing satisfactory fit (RMSEA at 0.042, CFI at 0.912). No multidimensional structure was identified, allowing the calculation of an overall discomfort score. The three highest discomforts were sleep deprivation, thirst, and perfusion lines and other devices, and the 3 lowest discomforts were limited visiting hours, hunger, and isolation. The overall discomfort score of the 18-item version of IPREA did not differ between men and women. Higher age was significantly correlated with a lower overall discomfort score. While MV was not linked to self-reported discomfort, patients treated by NIV reported higher overall discomfort scores than patients not treated by NIV.

Conclusion: The 18-item version of IPREA is easy to use and possesses satisfactory psychometric properties. The availability of a reliable and valid French questionnaire asking about patients' self-perceived ICU discomforts enables feedback from the health care team to be incorporated in a continuous quality health care improvement strategy.

Trial Registration: clinicaltrial.gov NCT02442934 (registration date: May 18, 2015, retrospectively registered).
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http://dx.doi.org/10.1186/s12955-019-1101-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367827PMC
February 2019

Tailored multicomponent program for discomfort reduction in critically ill patients may decrease post-traumatic stress disorder in general ICU survivors at 1 year.

Intensive Care Med 2019 02 30;45(2):223-235. Epub 2019 Jan 30.

Réanimation Médicale, CHU Saint-Louis, AP-HP, Paris, France.

Purpose: Reducing discomfort in the intensive care unit (ICU) should have a positive effect on long-term outcomes. This study assessed whether a tailored multicomponent program for discomfort reduction was effective in reducing post-traumatic stress disorder (PTSD) symptoms at 1 year in general ICU survivors.

Methods: This study is a prospective observational comparative effectiveness cohort study involving 30 ICUs. It was an extension of the IPREA3 study, a cluster-randomized controlled trial designed to assess the efficacy of a tailored multicomponent program to reduce discomfort in critically ill patients. The program included assessment of ICU-related self-perceived discomforts, immediate and monthly feedback to the healthcare team, and site-specific tailored interventions. The exposure was the implementation of this program. The eligible patients were exposed versus unexposed general adult ICU survivors. The prevalence of substantial PTSD symptoms at 1 year was assessed based on the Impact of Event Scale-Revised (IES-R).

Results: Of the 1537 ICU survivors included in the study, 475 unexposed patients and 344 exposed patients had follow-up data at 1 year: 57 (12.0%) and 21 (6.1%) presented with PTSD at 1 year, respectively (p = 0.004). Considering the clustering and after adjusting for age, gender, McCabe classification, and ICU-related self-perceived overall discomfort score, exposed patients were significantly less likely than unexposed patients to have substantial PTSD symptoms at 1 year (p = 0.015).

Conclusions: Implementation of a tailored multicomponent program in the ICU that has proved to be effective for reducing self-perceived discomfort in general adult ICU survivors also reduced the prevalence of substantial PTSD symptoms at 1 year.

Trial Registration: ClinicalTrials.gov identifier NCT02762409.
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http://dx.doi.org/10.1007/s00134-018-05511-yDOI Listing
February 2019

Being Convinced and Taking Responsibility: A Qualitative Study of Family Members' Experience of Organ Donation Decision and Bereavement After Brain Death.

Crit Care Med 2019 04;47(4):526-534

Famiréa Research Group, Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Saint-Louis University Hospital, Paris, France.

Objectives: Family members of brain dead patients experience an unprecedented situation in which not only they are told that their loved one is dead but are also asked to consider organ donation. The objective of this qualitative study was to determine 1) what it means for family members to make the decision and to take responsibility, 2) how they interact with the deceased patient in the ICU, 3) how family members describe the impact of the process and of the decision on their bereavement process.

Design: Qualitative study using interviews with bereaved family members who were approached for organ donation after the death of their relative in the ICU (brain death).

Setting: Family members from 13 ICUs in France.

Subjects: Bereaved family members who were approached for organ donation after the death of their relative in the ICU (brain death).

Intervention: None.

Measurements And Results: Twenty-four interviews were conducted with 16 relatives of organ donor patients and with eight relatives of nonorgan donor patients. Three themes emerged: 1) taking responsibility-relatives explain how they endorse decisional responsibility but do not experience it as a burden, on the contrary; 2) ambiguous perceptions of death-two groups of relatives emerge: those for whom ambiguity hinders their acceptance of the patient's death; those for whom ambiguity is an opportunity to accept the death and say goodbye; and 3) donation as a comfort during bereavement.

Conclusions: In spite of caregivers' efforts to focus organ donation discussions and decision on the patient, family members feel a strong decisional responsibility that is not experienced as a burden but a proof of their strong connection to the patient. Brain death however creates ambivalent experiences that some family members endure whereas others use as an opportunity to perform separation rituals. Last, organ donation can be experienced as a form of comfort during bereavement provided family members remain convinced their decision was right.
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http://dx.doi.org/10.1097/CCM.0000000000003616DOI Listing
April 2019

Diagnostic biologique des angioedèmes bradykiniques : les recommandations du CREAK.

Presse Med 2019 Jan 8;48(1 Pt 1):55-62. Epub 2018 Nov 8.

Centre de référence national des angioedèmes (CREAK), 38043 Grenoble, France; Service d'immunologie, CHUGA, 38043 Grenoble, France.

Bradykinin mediated angioedema (BK-AE) can be associated either with C1Inhibitor deficiency (hereditary and acquired forms), either with normal C1Inh (hereditary form and drug induced AE as angiotensin converting enzyme inhibitors…). In case of high clinical suspicion of BK-AE, C1Inh exploration must be done at first: C1Inh function and antigenemy as well as C4 concentration. C1Inh deficiency is significant if the tests are below 50 % of the normal values and controlled a second time. In case of C1Inh deficiency, you have to identify hereditary from acquired forms. C1q and anti-C1Inh antibody tests are useful for acquired BK-AE. SERPING1 gene screening must be done if a hereditary angioedema is suspected, even if there is no family context (de novo mutation 15 %). If a hereditary BK-AE with normal C1Inh is suspected, F12 and PLG gene screening is suitable.
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http://dx.doi.org/10.1016/j.lpm.2018.06.015DOI Listing
January 2019

Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study.

Intensive Care Med 2018 04 16;44(4):428-437. Epub 2018 Apr 16.

Department of Biostatistics and Clinical Research, CHU de Caen, 14000, Caen, France.

Purpose: To compare the efficacy of an antibiotic protocol guided by serum procalcitonin (PCT) with that of standard antibiotic therapy in severe acute exacerbations of COPD (AECOPDs) admitted to the intensive care unit (ICU).

Methods: We conducted a multicenter, randomized trial in France. Patients experiencing severe AECOPDs were assigned to groups whose antibiotic therapy was guided by (1) a 5-day PCT algorithm with predefined cutoff values for the initiation or stoppage of antibiotics (PCT group) or (2) standard guidelines (control group). The primary endpoint was 3-month mortality. The predefined noninferiority margin was 12%.

Results: A total of 302 patients were randomized into the PCT (n = 151) and control (n = 151) groups. Thirty patients (20%) in the PCT group and 21 patients (14%) in the control group died within 3 months of admission (adjusted difference, 6.6%; 90% CI - 0.3 to 13.5%). Among patients without antibiotic therapy at baseline (n = 119), the use of PCT significantly increased 3-month mortality [19/61 (31%) vs. 7/58 (12%), p = 0.015]. The in-ICU and in-hospital antibiotic exposure durations, were similar between the PCT and control group (5.2 ± 6.5 days in the PCT group vs. 5.4 ± 4.4 days in the control group, p = 0.85 and 7.9 ± 8 days in the PCT group vs. 7.7 ± 5.7 days in the control group, p = 0.75, respectively).

Conclusion: The PCT group failed to demonstrate non-inferiority with respect to 3-month mortality and failed to reduce in-ICU and in-hospital antibiotic exposure in AECOPDs admitted to the ICU.
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http://dx.doi.org/10.1007/s00134-018-5141-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5924665PMC
April 2018

Grief Symptoms in Relatives Who Experienced Organ Donation Requests in the ICU.

Am J Respir Crit Care Med 2018 09;198(6):751-758

1 Famiréa Research Group and.

Rationale: Studies show that the quality of end-of-life communication and care have a significant impact on the living long after the death of a relative and have been implicated in the burden of psychological symptoms after the ICU experience. In the case of organ donation, the patient's relatives are centrally involved in the decision-making process; yet, few studies have examined the impact of the quality of communication on the burden of psychological symptoms after death.

Objectives: To assess the experience of the organ donation process and grief symptoms in relatives of brain-dead patients who discussed organ donation in the ICU.

Methods: We conducted a multicenter longitudinal study in 28 ICUs in France. Participants were the relatives of brain-dead patients who were approached to discuss organ donation. Relatives were followed-up by phone at three time points: at 1 month, to complete a questionnaire describing their experience of the organ donation process; at 3 months, to complete the Hospital Anxiety and Depression Scale and the Impact of Event Scale-Revised; and at 9 months, to complete the Impact of Event Scale-Revised and the Inventory of Complicated Grief.

Measurements And Main Results: In total, 202 relatives of 202 patients were included, of whom 158 consented to and 44 refused organ donation. Interviews were conducted at 1, 3, and 9 months with 78%, 68%, and 58% of relatives, respectively. The overall experience of the organ donation process was significantly more burdensome for relatives of nondonors. They were more dissatisfied with communication (27% vs. 10%; P = 0.021), more often shocked by the request (65% vs. 19%; P < 0.0001), and more often found the decision difficult (53% vs. 27%; P = 0.017). However, there were no significant differences in grief symptoms measured at 3 and 9 months between the two groups. Understanding of brain death was associated with grief symptoms; our results show a higher prevalence of complicated grief symptoms among relatives who did not understand the brain death process than among those who did (75% vs. 46.1%; P = 0.026).

Conclusions: Experience of the organ donation process varied between relatives of donor versus nondonor patients, with relatives of nondonors experiencing lower-quality communication, but the decision was not associated with subsequent grief symptoms. Importantly, understanding of brain death is a key element of the organ donation process for relatives.
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http://dx.doi.org/10.1164/rccm.201709-1899OCDOI Listing
September 2018

Specialist Advice Support for Management of Severe Hereditary Angioedema Attacks: A Multicenter Cluster-Randomized Controlled Trial.

Ann Emerg Med 2018 08 2;72(2):194-203.e1. Epub 2018 Mar 2.

AP-HP, Urgences-Samu 93, hôpital Avicenne, Université Paris 13, Inserm U942, Bobigny, France; Inserm U942.

Study Objective: Hereditary angioedema is a rare disease associated with unpredictable, recurrent attacks of potentially life-threatening edema. Management of severe attacks is currently suboptimal because emergency medical teams are often unaware of new specific treatments. The objective of this trial is to test whether a dedicated national telephone care-management strategy would reduce resource use during severe hereditary angioedema attacks.

Methods: We conducted a cluster-randomized multicenter prospective trial of patients with a documented diagnosis of hereditary angioedema (type I, II or FXII hereditary angioedema). Participants were enrolled between March 2013 and June 2014 at 8 participating reference centers. The randomized units were the reference centers (clusters). Patients in the intervention arm were given a national free telephone number to call in the event of a severe attack. Emergency physicians in the SOS-hereditary angiœdema (SOS-HAE) call center were trained to advise or prescribe specific treatments. The primary outcome was number of admissions for angioedema attacks. Economic evaluation was also performed.

Results: We included 100 patients in the SOS-HAE group and 100 in the control group. During the 2 years, there were 2,368 hereditary angioedema attacks among 169 patients (85%). Mean number of hospital admissions per patient in the 2-year period was significantly greater in the usual-practice group (mean 0.16 [range 0 to 2] versus 0.03 [range 0 to 1]); patient risk difference was significant: -0.13 (95% confidence interval -0.22 to -0.04; P=.02). Probabilistic sensitivity graphic analysis indicated a trend toward increased quality-adjusted life-years in the SOS-HAE group.

Conclusion: A national dedicated call center for management of severe hereditary angioedema attacks is associated with a decrease in hospital admissions and may be cost-effective if facilities and staff are available to deliver the intervention alongside existing services.
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http://dx.doi.org/10.1016/j.annemergmed.2018.01.053DOI Listing
August 2018

Uncontrolled donation after circulatory death: comparison of two kidney preservation protocols on graft outcomes.

BMC Nephrol 2018 01 8;19(1). Epub 2018 Jan 8.

Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, service d'Anesthésie Réanimation, Lyon, France.

Background: Kidney transplantation following uncontrolled donation after circulatory death (uDCD) presents a high risk of delayed graft function due to prolonged warm ischemia time. In order to minimise the effects of ischemia/reperfusion injury during warm ischemia, normothermic recirculation recently replaced in situ perfusion prior to implantation in several institutions. The aim of this study was to compare these preservation methods on kidney graft outcomes.

Methods: The primary endpoint was the one-year measured graft filtration rate (mGFR). We collected retrospective data from 64 consecutive uDCD recipients transplanted over a seven-year period in a single centre.

Results: Thirty-two grafts were preserved by in situ perfusion and 32 by normothermic recirculation. The mean ± SD mGFR at 1 year post-transplantation was 43.0 ± 12.8 mL/min/1.73 m in the in situ perfusion group and 53.2 ± 12.8 mL/min/1.73 m in the normothermic recirculation group (p = 0.01). Estimated GFR levels were significantly higher in the normothermic recirculation group at 12 months (p = 0.01) and 24 months (p = 0.03) of follow-up. We did not find any difference between groups regarding patient and graft survival, delayed graft function, graft rejection, or interstitial fibrosis.

Conclusions: Function of grafts preserved by normothermic recirculation was better at 1 year and the results suggest that this persists at 2 years, although no difference was found in short-term outcomes. Despite the retrospective design, this study provides an additional argument in favour of normothermic recirculation.
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http://dx.doi.org/10.1186/s12882-017-0805-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5759186PMC
January 2018

A tailored multicomponent program to reduce discomfort in critically ill patients: a cluster-randomized controlled trial.

Intensive Care Med 2017 Dec 27;43(12):1829-1840. Epub 2017 Nov 27.

Unité de Recherche EA3279, Aix-Marseille Université, Marseille, France.

Purpose: Critically ill patients are exposed to stressful conditions and experience several discomforts. The primary objective was to assess whether a tailored multicomponent program is effective for reducing self-perceived discomfort.

Methods: In a cluster-randomized two-arm parallel trial, 34 French adult intensive care units (ICUs) without planned interventions to reduce discomfort were randomized, 17 to the arm including a 6-month period of program implementation followed by a 6-month period without the program (experimental group), and 17 to the arm with an inversed sequence (control group). The tailored multicomponent program consisted of assessment of ICU-related self-perceived discomforts, immediate and monthly feedback to healthcare teams, and site-specific tailored interventions. The primary outcome was the overall discomfort score derived from the 16-item IPREA questionnaire (0, minimal, 100, maximal overall discomfort) and the secondary outcomes were the discomfort scores of each IPREA item. IPREA was administered on the day of ICU discharge with a considered timeframe from the ICU admission until ICU discharge.

Results: During a 1-month assessment period, 398 and 360 patients were included in the experimental group and the control group, respectively. The difference (experimental minus control) of the overall discomfort score between groups was - 7.00 (95% CI - 9.89 to - 4.11, p < 0.001). After adjustment (age, gender, ICU duration, mechanical ventilation duration, and type of admission), the program effect was still positive for the overall discomfort score (difference - 6.35, SE 1.23, p < 0.001) and for 12 out of 16 items.

Conclusions: This tailored multicomponent program decreased self-perceived discomfort in adult critically ill patients.

Trial Registration: Clinicaltrials.gov Identifier NCT02442934.
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http://dx.doi.org/10.1007/s00134-017-4991-xDOI Listing
December 2017

The ICU-Diary study: prospective, multicenter comparative study of the impact of an ICU diary on the wellbeing of patients and families in French ICUs.

Trials 2017 Nov 15;18(1):542. Epub 2017 Nov 15.

Department of Intensive Care, Dieppe General Hôpital, Dieppe, France.

Background: Post-intensive care syndrome includes the multiple consequences of an intensive care unit (ICU) stay for patients and families. It has become a new challenge for intensivists. Prevention programs have been disappointing, except for ICU diaries, which report the patient's story in the ICU. However, the effectiveness of ICU diaries for patients and families is still controversial, as the interpretation of the results of previous studies was open to criticism hampering an expanded use of the diary. The primary objective of the study is to evaluate the post-traumatic stress syndrome in patients. The secondary objectives are to evaluate the post-traumatic stress syndrome in families, anxiety and depression symptoms in patients and families, and the recollected memories of patients. Endpoints will be evaluated 3 months after ICU discharge or death.

Methods: A prospective, multicenter, randomized, assessor-blind comparative study of the effect of an ICU diary on patients and families. We will compare two groups: one group with an ICU diary written by staff and family and given to the patient at ICU discharge or to the family in case of death, and a control group without any ICU diary. Each of the 35 participating centers will include 20 patients having at least one family member who will likely visit the patient during their ICU stay. Patients must be ventilated within 48 h after ICU admission and not have any previous chronic neurologic or acute condition responsible for cognitive impairments that would hamper their participation in a phone interview. Three months after ICU discharge or death of the patient, a psychologist will contact the patient and family by phone. Post-traumatic stress syndrome will be evaluated using the Impact of Events Scale-Revised questionnaire, anxiety and depression symptoms using the Hospital Anxiety and Depression Scale questionnaire, both in patients and families, and memory recollection using the ICU Memory Tool Questionnaire in patients. The content of a randomized sample of diaries of each center will be analyzed using a grid. An interview of the patients in the intervention arm will be conducted 6 months after ICU discharge to analyze in depth how they use the diary.

Discussion: This study will provide new insights on the impact of ICU diaries on post-traumatic stress disorders in patients and families after an ICU stay.

Trial Registration: ClinicalTrial.gov, ID: NCT02519725 . Registered on 13 July 2015.
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http://dx.doi.org/10.1186/s13063-017-2283-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5688734PMC
November 2017

Assessment of sepsis-induced immunosuppression at ICU discharge and 6 months after ICU discharge.

Ann Intensive Care 2017 Dec 2;7(1):80. Epub 2017 Aug 2.

Department of Anesthesiology and Critical Care Medicine, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France.

Background: Increase in mortality and in recurrent infections in the year following ICU discharge continues in survivors of septic shock, even after total clinical recovery from the initial septic event and its complications. This supports the hypothesis that sepsis could induce persistent long-term immune dysfunctions. To date, there is almost no data on ICU discharge and long-term evolution of sepsis-induced immunosuppression in septic shock survivors. The aim of this study was to assess the persistence of sepsis-induced immunosuppression by measuring expression of human leukocyte antigen DR on monocytes (mHLA-DR), CD4+ T cells, and regulatory T cells (Treg) at ICU discharge and 6 months after ICU discharge in patients admitted to the ICU for septic shock.

Methods: In this prospective observational study, septic shock survivors with no preexisting immune suppression or treatment interfering with the immune system were included. mHLA-DR, CD4+ T cells, and Treg expression were assessed on day 1-2, 3-4, and 6-8 after ICU admission, at ICU discharge, and 6 months after ICU discharge.

Results: A total of 40 patients were enrolled during their ICU stay: 21 males (52.5%) and 19 females, median age 68 years (IQR 58-77), median SOFA score on day 1-2 was 8 (IQR 7-9), and median ICU length of stay was 11 days (IQR 7-24). Among these 40 patients, 33 were studied at ICU discharge and 15 were disposed for blood sampling 6 months after ICU discharge. On day 1-2, mHLA-DR expression was abnormally low for all patients [median 4212 (IQR 2640-6047) AB/C] and remained abnormally low at ICU discharge for 75% of them [median 10,281 (IQR 7719-13,035) AB/C]. On day 3-4, 46% of patients presented CD4+ lymphopenia [median 515 (IQR 343-724) mm] versus 34% at ICU discharge [median 642 (IQR 459-846) mm]. Among patients with a 6-month blood sample, normal values of mHLA-DR were found for all patients [median 32,616 (IQR 24,918-38,738) AB/C] except for one and only another one presented CD4+ lymphopenia.

Conclusions: While immune alterations persist at ICU discharge, there is, at cellular level, no persistent immune alterations among septic shock survivors analyzed 6 months after ICU discharge.
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http://dx.doi.org/10.1186/s13613-017-0304-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540741PMC
December 2017

Transthoracic echography assessment of the superior vena cava flow: a pilot study.

Intensive Care Med 2017 11 20;43(11):1738-1739. Epub 2017 Jun 20.

Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.

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http://dx.doi.org/10.1007/s00134-017-4865-2DOI Listing
November 2017

Association between mRNA expression of CD74 and IL10 and risk of ICU-acquired infections: a multicenter cohort study.

Intensive Care Med 2017 Jul 5;43(7):1013-1020. Epub 2017 May 5.

Hospices Civils de Lyon, bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France.

Purpose: Intensive care unit (ICU)-acquired infections (IAI) result in increased hospital and ICU stay, costs and mortality. To date, no biomarker has shown sufficient evidence and ease of application in clinical routine for the identification of patients at risk of IAI. We evaluated the association of the systemic mRNA expression of two host response biomarkers, CD74 and IL10, with IAI occurrence in a large cohort of ICU patients.

Methods: ICU patients were prospectively enrolled in a multicenter cohort study. Whole blood was collected on the day of admission (D1) and on day 3 (D3) and day 6 (D6) after admission. Patients were screened daily for IAI occurrence and data were censored after IAI diagnosis. mRNA expression levels of biomarkers were measured using RT-qPCR. Fine and Gray competing risk models were used to assess the association between gene expression and IAI occurrence.

Results: A total of 725 patients were analyzed. At least one IAI episode occurred in 137 patients (19%). After adjustment for shock and sepsis status at admission, CD74 and IL10 levels were found to be significantly associated with IAI occurrence [subdistribution hazard ratio (95% confidence interval) 0.67 (0.46-0.97) for CD74 D3/D1 expression ratio and 2.21 (1.63-3.00) for IL10 at D3]. IAI cumulative incidence was significantly different between groups stratified according to CD74 or IL10 expression (Gray tests p < 0.001).

Conclusion: Our results suggest that two immune biomarkers, CD74 and IL10, could be relevant tools for the identification of IAI risk in ICU patients.
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http://dx.doi.org/10.1007/s00134-017-4805-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487586PMC
July 2017

Hereditary angioedema with normal C1 inhibitor: clinical characteristics and treatment response with plasma-derived human C1 inhibitor concentrate (Berinert) in a French cohort.

Eur J Dermatol 2017 Apr;27(2):155-159

National Reference Centre for Angioedema, CREAK, France, Department of Internal Medicine, Saint Antoine University Hospital, AP-HP, Paris, France.

Hereditary angioedema (HAE) is a rare genetic disorder characterised by episodes of swelling without urticaria. Berinert® (CSL Behring) is a plasma-derived human C1 inhibitor (C1-INH) concentrate, approved for the treatment of HAE with C1-INH deficiency (C1-INH-HAE), however, it is often used off-label in Europe to treat HAE with normal C1-INH. To report the clinical characteristics of patients with HAE with normal C1-INH (with F12 gene mutation; FXII-HAE) or of unknown origin (U-HAE), and their response to Berinert®. Data from 2007 to 2016 (obtained retrospectively from the French Cohort BeRinert Angiœdème [COBRA] registry of HAE patients with everyday use of Berinert) were analysed; no control group was included. Diagnostic criteria for FXII-HAE and U-HAE included a normal C1-INH antigenic level and function and refractoriness to high-dose antihistamines. For FXII-HAE, diagnosis also included F12 gene mutation, and U-HAE a positive family history for the disease. To date, 28 patients with FXII-HAE or U-HAE were identified (mean age: 27 years; first angioedema attack at 19.8 years; 85.7% female) with 78 documented Berinert-treated attacks, the majority occurring in the laryngeal and abdominal regions. Efficacy assessment of Berinert was available for 38 of 78 documented Berinert-treated attacks; 22 improved within 60 minutes of treatment initiation, nine within 60-180 minutes, four after 180 minutes, and three showed no improvement. No severe or serious adverse effects were reported. Data to date suggest that Berinert may be a safe and efficacious treatment option for the majority of HAE patients.
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http://dx.doi.org/10.1684/ejd.2016.2948DOI Listing
April 2017

Diagnosis and treatment of upper airway oedema caused by acute angio-oedema in the emergency department: a French consensus statement.

Eur J Emerg Med 2017 Oct;24(5):318-325

aDepartment of Anaesthesiology and Intensive care, Edouard Herriot University Hospital bDepartment of Clinical Research and Innovation, Hospices Civils de Lyon, Lyon cEmergency Department, Louis Mourier University Hospital, Paris 7 University dDepartment of Internal Medicine, Saint Antoine University Hospital, Paris 6 University, Assistance Publique-Hôpitaux de Paris, Paris eDepartment of Internal Medicine, Grenoble University Hospital, Grenoble-Alpes University, Grenoble fDepartment of Dermatology, Gabriel-Montpied University Hospital, Clermont-Ferrand gDepartment of Internal Medicine, Niort Hospital, Niort hDepartment of Internal Medicine, Archet 1 University Hospital, Nice Sophia-Antipolis University, Nice iDepartment of Medicine, Saint Louis University Hospital, Saint Pierre, Réunion jDepartment of Internal Medicine, Caen University Hospital, Caen kDepartment of Dermatology and Allergology, Grenoble University Hospital, Grenoble lDepartment of Internal Medicine, Timone University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille mDepartment of Dermatology, Saint Eloi University Hospital, Montpellier nDepartment of Dermatology, Besançon University Hospital, Franche-Comté University, INSERM UMR 1098, Besançon oDepartment of Internal Medicine Toulouse University Hospital, Toulouse University, Toulouse pDepartment of Internal Medicine, Lille University Hospital, Lille University, INSERM U995 Lille, Lille, France.

Angio-oedema is a transitory, localized, noninflammatory oedema of subcutaneous tissue or mucous. When the oedema affects the mouth, lips, tongue or larynx, it can result in fatal asphyxiation in the absence of specific treatment. Oedema secondary to plasma extravasation is usually mediated by either histamine or bradykinin. As laboratory tests are not available in an emergency setting, the implicated mediator cannot be readily determined. The challenge for the emergency physician is to determine the aetiological type, evaluate severity and initiate adapted treatment by means of a structured approach. A team of experts from the French Reference Centre for Angio-oedema reached a consensus for recommendations for the diagnostic and therapeutic strategy to be adopted by emergency departments faced with angio-oedema of the upper airways in adults. The experts defined 11 important questions. Responses were rated using a two-round Delphi methodology. The 11 recommendations were related to triage on admission, a step-by-step diagnostic protocol, definition of attack severity, discouragement of instrumental examination, prioritization of treatment for severe attacks according to clinical signs and anticipation of access to specific treatments by the hospital. Angio-oedema of the upper airways can be fatal and requires anticipation by the emergency department. A search for the aetiology, an evaluation of clinical symptoms and the availability of the treatments are challenges justifying these recommendations.
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http://dx.doi.org/10.1097/MEJ.0000000000000446DOI Listing
October 2017

Invasive meningococcal disease-induced myocarditis in critically ill adult patients: initial presentation and long-term outcome.

Intensive Care Med 2017 Feb 23;43(2):279-281. Epub 2016 Nov 23.

Service de Réanimation Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon, France.

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http://dx.doi.org/10.1007/s00134-016-4623-xDOI Listing
February 2017

Outbreak of pulmonary Pseudomonas aeruginosa and Stenotrophomonas maltophilia infections related to contaminated bronchoscope suction valves, Lyon, France, 2014.

Euro Surveill 2016 Jul;21(28)

Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.

In April 2014, pulmonary Pseudomonas aeruginosa and Stenotrophomonas maltophilia co-infections potentially related to bronchoscopic procedures were identified in the intensive care units of a university hospital in Lyon, France. A retrospective cohort of 157 patients exposed to bronchoscopes from 1 December 2013 to 17 June 2014 was analysed. Environmental samples of suspected endoscopes were cultured. Bronchoscope disinfection was reviewed. Ten cases of pulmonary P. aeruginosa/S. maltophilia co-infections were identified, including two patients with secondary pneumonia. Eight cases were linked to bronchoscope A1 and two to bronchoscope A2. Cultures deriving from suction valves were positive for P. aeruginosa/S. maltophilia. Exposure to bronchoscopes A1 and A2 was independently coupled with increased risk of co-infection (adjusted odds ratio (aOR) = 84.6; 95% confidence interval (CI): 9.3-771.6 and aOR = 11.8, 95% CI: 1.2-121.3). Isolates from suction valves and clinical samples presented identical pulsotypes. The audit detected deficiencies in endoscope disinfection. No further cases occurred after discontinuation of the implicated bronchoscopes and change in cleaning procedures. This outbreak of pulmonary P. aeruginosa/S. maltophilia co-infections was caused by suction valve contamination of two bronchoscopes of the same manufacturer. Our findings underscore the need to test suction valves, in addition to bronchoscope channels, for routine detection of bacteria.
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http://dx.doi.org/10.2807/1560-7917.ES.2016.21.28.30286DOI Listing
July 2016

Decreased CX3CR1 messenger RNA expression is an independent molecular biomarker of early and late mortality in critically ill patients.

Crit Care 2016 Jun 30;20(1):204. Epub 2016 Jun 30.

Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France.

Background: Chemokine (C-X3-C motif) receptor 1 (CX3CR1) was identified as the most differentially expressed gene between survivors and non-survivors in two independent cohorts of septic shock patients and was proposed as a marker of sepsis-induced immunosuppression. Whether such a biomarker is associated with mortality in the heterogeneous group of critically ill patients is unknown. The primary objective of this study was to evaluate the association between CX3CR1 messenger RNA (mRNA) expression and mortality in intensive care unit (ICU) patients. The secondary objective was to evaluate similar endpoints in the subgroup of septic shock patients.

Methods: We performed a prospective, multicentre, non-interventional study in six ICUs of university hospitals in Lyon, France. Every consecutive adult patient with systemic inflammatory response syndrome and an expected length of stay in the ICU over 2 days was included. Whole-blood CX3CR1 mRNA expression was measured by quantitative real-time polymerase chain reaction at day 1 (D1) and D3 after inclusion.

Results: In ICU patients (n = 725), decreased CX3CR1 mRNA expression at D1 was associated with high D7 mortality (AUC 0.70, adjusted OR [aOR] 2.03, 95 % CI 1.19-3.46), while decreased expression at D3 was associated with increased D28 mortality (AUC 0.64, aOR 2.34, 95 % CI 1.45-3.77). In septic shock patients (n = 279), similar associations were observed between decreased D1 CX3CR1 mRNA expression and D7 mortality (AUC 0.69, aOR 2.76, 95 % CI 1.32-5.75) as well as decreased D3 expression and D28 mortality (AUC 0.72, aOR 3.98, 95 % CI 1.72-9.23). These associations were independent of lactacidaemia, Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment score and Charlson comorbidity index.

Conclusions: This study represents the largest evaluation of such an mRNA marker in a heterogeneous cohort of severely injured patients. Our results show that decreased CX3CR1 mRNA expression is associated with increased mortality in ICU patients. This suggests a link between injury-induced immunosuppression and mortality in critically ill patients. In this context, the monitoring of such a host response molecular biomarker could prove very helpful for the identification of patients at high risk of death in the ICU.
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http://dx.doi.org/10.1186/s13054-016-1362-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4929760PMC
June 2016

Dedicated call center (SOS-HAE) for hereditary angioedema attacks: study protocol for a randomised controlled trial.

Trials 2016 Apr 30;17(1):225. Epub 2016 Apr 30.

SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France.

Background: Despite the availability of guidelines for the specific treatment of hereditary angioedema (HAE) attacks, HAE morbidity and mortality rates remain substantial. HAE attacks are a major medical issue requiring specific treatment as well as a considerable socio-economic burden. We report a protocol designed to test whether a dedicated call centre is more effective than usual practice in the management of patients experiencing an HAE attack.

Methods/design: This prospective, cluster-randomised, single-blind, parallel-group, multicentre trial evaluates the morbidity and consequent socio-economic costs of the management of patients experiencing an HAE attack by a dedicated call centre as compared to usual practice. The trial aims to recruit 200 patients. Patients in the intervention arm are provided with an SOS-HAE card with the call centre's freephone number that they can access in the case of an attack. The centre's mission is to provide recommended expert advice on early home treatment. The centre can route the call to a local emergency medical service with competency in HAE management or even arrange for the drugs needed for the specific treatment of an HAE attack to be sent to the emergency department of the local hospital. The primary outcome measure is the number of hospital admissions for an HAE attack. Each patient will be followed up every 2 months for 2 years. The study has been approved by the ethics committee (Comité de Protection des Personnes d'Ile de France 10; registration number: 2012-A00044-39; date of approval: 19 January 2012).

Discussion: The SOS-HAE protocol has been designed to address the handling of attacks experienced by patients with HAE in the home. The proposed trial will determine whether the setting up of a dedicated call centre is more effective than usual practice in terms of reducing morbidity as given by the numbers of hospital admissions. The results are also anticipated to have important implications in terms of socio-economic costs for both healthcare services and patients.

Trial Registration: ClinicalTrials.gov NCT01679912 .
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http://dx.doi.org/10.1186/s13063-016-1350-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853856PMC
April 2016

CAESAR: a new tool to assess relatives' experience of dying and death in the ICU.

Intensive Care Med 2016 Jun 7;42(6):995-1002. Epub 2016 Mar 7.

Caen University Hospital, Caen, France.

Purpose: To develop an instrument designed specifically to assess the experience of relatives of patients who die in the intensive care unit (ICU).

Methods: The instrument was developed using a mixed methodology and validated in a prospective multicentre study. Relatives of patients who died in 41 ICUs completed the questionnaire by telephone 21 days after the death, then completed the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised and Inventory of Complicated Grief after 3, 6, and 12 months.

Results: A total of 600 relatives were included, 475 in the main cohort and 125 in the reliability cohort. The 15-item questionnaire, named CAESAR, covered the patient's preferences and values, interactions with/around the patient and family satisfaction. We defined three groups based on CAESAR score tertiles: lowest (≤59, n = 107, 25.9 %), middle (n = 185, 44.8 %) and highest (≥69, n = 121, 29.3 %). Factorial analysis showed a single dimension. Cronbach's alpha in the main and reliability cohorts was 0.88 (0.85-0.90) and 0.85 (0.79-0.89), respectively. Compared to a high CAESAR score, a low CAESAR score was associated with greater risks of anxiety and depression at 3 months [1.29 (1.13-1.46), p = 0.001], post-traumatic stress-related symptoms at 3 [1.34 (1.17-1.53), p < 0.001], 6 [OR = 1.24 (1.06-1.44), p = 0.008] and 12 [OR = 1.26 (1.06-1.50), p = 0.01] months and complicated grief at 6 [OR = 1.40 (1.20-1.63), p < 0.001] and 12 months [OR = 1.27 (1.06-1.52), p = 0.01].

Conclusions: The CAESAR score 21 days after death in the ICU is strongly associated with post-ICU burden in the bereaved relatives. The CAESAR score should prove a useful primary endpoint in trials of interventions to improve relatives' well-being.
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http://dx.doi.org/10.1007/s00134-016-4260-4DOI Listing
June 2016

Hepatic Compartment Syndrome Following Percutaneous Cholecystostomy: A Case Report.

Crit Care Med 2016 Mar;44(3):e174-7

1Department of Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.2Department of Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.

Objective: To describe a case of hepatic subcapsular hematoma causing an acute Budd-Chiari-like syndrome, leading to hepatic compartment syndrome, which combines compression of intrahepatic vessels on CT, acute liver failure, and refractory shock.

Design: Case report.

Setting: Surgical ICU of a university teaching hospital.

Patient: Single case: A 64-year-old man hospitalized for 1 month in the ICU after multiple complications following bypass surgery, under anticoagulation after a recent aortic valve replacement and without a medical history of hepatic disease, underwent a percutaneous cholecystostomy for acute calculous cholecystitis. Fifteen days later, he presented with acute anemia, abdominal tenderness, severe hepatic cytolysis, metabolic acidosis, and hemodynamic dysfunction. CT showed a voluminous subcapsular hematoma compressing the hepatic parenchyma, which appeared ischemic with a flattened right lobar portal vein and vena cava without any visible active bleeding.

Interventions: Arteriography and evacuation of the hematoma under ultrasound guidance (while managing hemodynamic dysfunction) were preferred to surgery given the patient's instability and surgical history.

Measurements And Main Results: Evidence of vessels and parenchymal compression with no source of bleeding was found despite removal of the cholecystostomy catheter. Two right sectorial inferior hepatic arteries were embolized. Hematoma was punctured to relieve pressure on hepatic parenchyma, retrieving 300 mL of blood. Unfortunately, liver failure worsened dramatically while patient developed refractory shock and died.

Conclusions: Hepatic compartment syndrome must be suspected when acute liver failure occurs in patients with subcapsular hematoma. Only early management may avoid a fatal outcome or the need for an emergency liver transplantation.
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http://dx.doi.org/10.1097/CCM.0000000000001403DOI Listing
March 2016

Early daily mHLA-DR monitoring predicts forthcoming sepsis in severe trauma patients.

Intensive Care Med 2015 Dec 10;41(12):2229-30. Epub 2015 Sep 10.

Laboratoire d'Immunologie, HCL, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.

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http://dx.doi.org/10.1007/s00134-015-4045-1DOI Listing
December 2015

Bradykinin-mediated angioedema: factors associated with admission to an intensive care unit, a multicenter study.

Eur J Emerg Med 2016 Jun;23(3):219-23

aEmergency Department bInternal Medicine, Reference Center for Angioedema (CRéAk), Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Groupe hospitalier Hôpitaux Universitaires Paris Seine-Saint-Denis, Université Paris Bondy cSAMU-SMUR 93 dClinical Research Department, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Groupe hospitalier Hôpitaux Universitaires Paris Seine-Saint-Denis, Université Paris Bobigny eDepartment of Anesthesiology and Intensive care Unit fInternal Medicine, Reference Center for Angioedema (CRéAk), Hôpital Edouard-Herriot, Hospices civils de Lyon gInternal Medicine, Reference Center for Angioedema (CRéAk), CHU de Grenoble, Grenoble hDepartment of Dermatology iIntensive Care Unit, Reference Center for Angioedema (CRéAk), UNAM Université, Hôpital d'Angers, Cedex jDepartment of Dermatology, Reference Center for Angioedema (CRéAk), CHU Gabriel-Montpied, Clermont-Ferrand kInternal Medicine, Centre Hospitalier du Centre de Bretagne, Pontivy lInternal Medicine, CHU de Caen, Caen, France.

Objective: Bradykinin-mediated angioedema is characterized by transient attacks of localized edema of subcutaneous or submucosal tissues and can be life-threatening when involving the upper airways. The aim of this study was to determine the features of acute attacks that might be associated with admission to an ICU.

Patients And Methods: We carried out a retrospective, multicenter, observational study in consecutive patients attending one of six reference centers in France for acute bradykinin-mediated angioedema attacks. Patients had been hospitalized for an acute episode at least once previously. Acute attacks requiring ICU admission were compared with acute attacks that had not required ICU admission.

Results: Overall, 118 acute attacks in 31 patients were analyzed (10 patients with hereditary angioedema, 19 patients with angiotensin-converting enzyme inhibitor-induced angioedema, and two patients with acquired C1-inhibitor deficiency angioedema). In multivariate analysis, upper airway involvement, corticosteroid, and C1-inhibitor concentrate administration were associated with ICU admission. Seven episodes (18%) needed airway protection. The evolution was favorable in 38 of 39 attacks warranting ICU admission: patients were able to get out of the service (mean ICU stay 4±5 days). One death was observed by asphyxiation because of laryngeal swelling.

Conclusion: Upper airway involvement is an independent risk factor for ICU admission. Corticosteroid use, which is an ineffective treatment, and C1-inhibitor concentrate use are factors for ICU admission. The presence of upper airway involvement should be a warning signal that the attack may be severe.
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http://dx.doi.org/10.1097/MEJ.0000000000000252DOI Listing
June 2016

Complicated grief after death of a relative in the intensive care unit.

Eur Respir J 2015 May 22;45(5):1341-52. Epub 2015 Jan 22.

For a list of the authors' affiliations see the Acknowledgements section.

An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score >25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives. Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements.
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http://dx.doi.org/10.1183/09031936.00160014DOI Listing
May 2015

[Emergency management of bradykinin-mediated angioedema].

Presse Med 2015 Jan 13;44(1):70-7. Epub 2014 Dec 13.

Hospices civils de Lyon, hôpital Édouard-Herriot, centre de référence multisites des angiœdèmes bradykiniques, département d'anesthésie-réanimation, 69437 Lyon, France.

In the emergency setting, the diagnosis of bradykinin-mediated angioedema is based exclusively on history and physical examination. Severe attacks must be identified because the evolution is unpredictable with a risk of life-threatening airway obstruction. Underestimate the severity of the attack is a management pitfall to avoid. All attack under the shoulders should be considered as severe and must benefit from early specific treatment.
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http://dx.doi.org/10.1016/j.lpm.2014.09.012DOI Listing
January 2015

Metabolic phenotyping of traumatized patients reveals a susceptibility to sepsis.

Anal Chem 2013 Nov 7;85(22):10850-5. Epub 2013 Nov 7.

Hospices Civils de Lyon, Service de réanimation, Hôpital Edouard Herriot , 5 place d'Arsonval, 69437 Lyon Cedex 03, France.

Sepsis is one of the leading causes of morbidity and mortality in patients admitted in intensive care units (ICU) for trauma. The identification of biochemical mechanisms and prediction of patients at risk of early sepsis remain unsolved. Metabolic phenotyping allows the recovery of coordinated metabolic concentration variations. There are no predictive metabolic phenotyping studies based on noninvasive human samples to identify the later development of sepsis in traumatized patients. The aim of this study was to investigate whether the metabolic phenotype could help in the discrimination of patients according to the later development of sepsis. Plasma samples were taken from severely injured patients in the hours following their admission in the ICU. Nuclear magnetic resonance (NMR) based metabolic phenotyping was performed on this prospective cohort. Statistical analyses were run on NMR spectra to discriminate patients according to the later development of sepsis. Twenty-two patients were included. One was excluded because of aberrant metabolic phenotype. Orthogonal partial least-squares analysis allowed the recovery of a predictive metabolic phenotype identifying patients with a later development of sepsis (1 + 4 component model, R(2) = 0.855, Q(2) = 0.384). A cross-validated receiver operator characteristic curve showed a remarkable prediction capacity (AUC = 0.778). Eight metabolic hotspots were identified. NMR-based metabolic phenotyping allows the prediction of patients at high risk of early sepsis after ICU admission for trauma. A larger cohort is necessary to validate and complete this study, understand biochemical mechanisms promoting sepsis development, and identify patients at risk.
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http://dx.doi.org/10.1021/ac402235qDOI Listing
November 2013