Publications by authors named "Claude Martin"

168 Publications

The global burden of musculoskeletal injury in low and lower-middle income countries: A systematic literature review.

OTA Int 2020 Jun 23;3(2):e062. Epub 2020 Apr 23.

Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, University of California San Francisco, San Francisco, CA.

Background: While the global burden of musculoskeletal injury is increasingly recognized, few epidemiologic studies have specifically recorded its incidence or prevalence, particularly in low- and middle-income countries. Understanding the burden of musculoskeletal injury relative to other health conditions is critical to effective allocation of resources to mitigate the disability that results from trauma. The current study aims to systematically review the existing primary literature on the incidence and prevalence of pelvic and appendicular fractures, a major component of musculoskeletal injury, in low- and lower-middle income countries (LMICs).

Methods: This study conforms to the systematic review and traditional meta-analysis guidelines outlined in the PRISMA-P statement. Incidence rates were calculated as the occurrence of new fracture cases per 100,000 person-years, and prevalence as total fracture cases per population sample, reported as percentages.

Results: The literature search yielded 3497 total citations. There were 21 full-text articles, representing 14 different countries, selected for data extraction. Included studies reported a wide range of incidence and prevalence rates, with an overall mean fracture incidence ranging from 779 (95% CI: 483.0-1188.7) to 1574 (95% CI: 1285.1-1915.1) per 100,000 person-years.

Conclusion: Better understanding the unmet burden of musculoskeletal injury in LMICs is critical to effectively allocating resources and advocating for underserved populations. To address existing gaps and heterogeneity within the literature, future research should incorporate population-based sampling with broader geographic representation in LMICs to more accurately capture the burden of disease.
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http://dx.doi.org/10.1097/OI9.0000000000000062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022900PMC
June 2020

When lockdown policies amplify social inequalities in COVID-19 infections: evidence from a cross-sectional population-based survey in France.

BMC Public Health 2021 04 12;21(1):705. Epub 2021 Apr 12.

Sorbonne University, Paris, France.

Background: Significant differences in COVID-19 incidence by gender, class and race/ethnicity are recorded in many countries in the world. Lockdown measures, shown to be effective in reducing the number of new cases, may not have been effective in the same way for all, failing to protect the most vulnerable populations. This survey aims to assess social inequalities in the trends in COVID-19 infections following lockdown.

Methods: A cross-sectional survey conducted among the general population in France in April 2020, during COVID-19 lockdown. Ten thousand one hundred one participants aged 18-64, from a national cohort who lived in the three metropolitan French regions most affected by the first wave of COVID-19. The main outcome was occurrence of possible COVID-19 symptoms, defined as the occurrence of sudden onset of cough, fever, dyspnea, ageusia and/or anosmia, that lasted more than 3 days in the 15 days before the survey. We used multinomial regression models to identify social and health factors related to possible COVID-19 before and during the lockdown.

Results: In all, 1304 (13.0%; 95% CI: 12.0-14.0%) reported cases of possible COVID-19. The effect of lockdown on the occurrence of possible COVID-19 was different across social hierarchies. The most privileged class individuals saw a significant decline in possible COVID-19 infections between the period prior to lockdown and during the lockdown (from 8.8 to 4.3%, P = 0.0001) while the decline was less pronounced among working class individuals (6.9% before lockdown and 5.5% during lockdown, P = 0.03). This differential effect of lockdown remained significant after adjusting for other factors including history of chronic disease. The odds of being infected during lockdown as opposed to the prior period increased by 57% among working class individuals (OR = 1.57; 95% CI: 1.00-2.48). The same was true for those engaged in in-person professional activities during lockdown (OR = 1.53; 95% CI: 1.03-2.29).

Conclusions: Lockdown was associated with social inequalities in the decline in COVID-19 infections, calling for the adoption of preventive policies to account for living and working conditions. Such adoptions are critical to reduce social inequalities related to COVID-19, as working-class individuals also have the highest COVID-19 related mortality, due to higher prevalence of comorbidities.
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http://dx.doi.org/10.1186/s12889-021-10521-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040364PMC
April 2021

Current use of inotropes in circulatory shock.

Ann Intensive Care 2021 Jan 29;11(1):21. Epub 2021 Jan 29.

Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.

Background: Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock.

Methods: From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions.

Results: A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81-90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement).

Conclusion: Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.
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http://dx.doi.org/10.1186/s13613-021-00806-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846624PMC
January 2021

The Malawi Orthopaedic Association/AO Alliance guidelines and standards for open fracture management in Malawi: a national consensus statement.

Malawi Med J 2020 09;32(3):112-118

AO Alliance, Davos, Switzerland.

Background: Open fractures are common injuries in Malawi that pose a large burden on the healthcare system and result in long-term disability.

Aim: Establishing a multiprofessional agreement on the management of open fractures in Malawi from a consensus meeting.

Methods: AO Alliance convened a consensus meeting to build an agreement on the management of open fractures in Malawi. Eighteen members from different professions and various regions of Malawi participated in a 1-day consensus meeting on 7 September 2019. Prior to the meeting the British Orthopaedic Audit Standards for Trauma (BOAST) for open fractures, as well as relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on open fracture management, followed by an open discussion meeting. At the 1-day consensus meeting panel members developed statements for each standard and guideline. Panel members then voted to accept or reject the statements.

Results: Substantial agreement (no rejections) was reached for all 17 guidelines and the associated terminology was agreed on. These guidelines were then presented to the members of the Malawi Orthopaedic Association (MOA) at their annual general meeting on 28 September 2019 and all participants agreed to adopt them.

Conclusions: These MOA/AO Alliance guidelines aim to set a standard for open fracture management that can be regularly measured and audited in Malawi to improve care for these patients.
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http://dx.doi.org/10.4314/mmj.v32i3.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812144PMC
September 2020

Prophylaxis and Treatment in Critically Ill Patients after Abdominal Surgery: A Survey of Practice.

Surg Infect (Larchmt) 2019 Sep 17;20(6):510-518. Epub 2019 May 17.

5Service d'Anesthésie et de Réanimation, Chemin des Bourrely, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France.

To survey current intensive care unit (ICU) practice in initiating antifungal therapy for prophylaxis and treatment of suspected candidiasis after abdominal surgery. The goal was to establish the need to prioritize research toward standardized care of such patients. Online questionnaire survey of clinical practice based on theoretical case scenarios. These were structured with expert input to investigate management of: hemodynamically stable/unstable patient after urgent upper/lower gastrointestinal surgery with/without fungal growth in culture. The link to the survey was sent to all active members of the European Society of Intensive Care Medicine (ESICM). The survey was completed by 101 respondents from 29 countries. Fewer than half (48.5%) stated that in their center, ICU antibiotic and antifungal therapy is managed by a dedicated specialist physician/team that manages all ICU patients. Respondents exhibited a greater tendency toward administering antifungal agents, mainly fluconazole, to hemodynamically unstable patients. One week after surgery for a perforated duodenal ulcer, only half responded they would use antifungal agents when a patient develops septic shock. Most respondents chose to administer antifungal therapy in patients with septic shock if had been identified in any culture. The source of infection, location of surgery, or type of were not viewed as triggers for therapeutic decisions. The current survey demonstrates large variability in antifungal use. Decisions are made irrespective of existing guidelines and seem to be driven by patient hemodynamic condition and identification of any Candida in any culture alone.
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http://dx.doi.org/10.1089/sur.2018.267DOI Listing
September 2019

Risk Factors for Delayed Presentation Among Patients with Musculoskeletal Injuries in Malawi.

J Bone Joint Surg Am 2019 May;101(10):920-931

The Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Background: The burden of injuries is high in low-income and middle-income countries such as Malawi, where access to musculoskeletal trauma care is limited. Delayed treatment can worsen trauma-related disability. Understanding risk factors for delayed hospital presentation will assist in guiding trauma system development.

Methods: We examined the records of 1,380 pediatric and adult patients with fractures who presented to the orthopaedic clinics of 2 urban referral hospitals and 2 rural district hospitals in Malawi. We used multivariate Poisson regression to evaluate the association between presentation to a hospital ≥2 days after the injury (delayed presentation) and 11 covariates: age, sex, education level, occupation, season of injury, day of injury, injury mechanism, injury type or extremity of injury, referral status, hospital of presentation, and estimated travel time.

Results: Twenty-eight percent of pediatric patients and 34% of adult patients presented late. In the pediatric cohort, fall (relative risk [RR], 1.40 [95% confidence interval (CI), 1.02 to 1.93]), sports injuries (RR, 1.65 [95% CI, 1.09 to 2.49]), tibial or fibular injuries (RR, 1.36 [95% CI, 1.05 to 1.77]), injury over the weekend (RR, 2.30 [95% CI, 1.88 to 2.80]), estimated travel time of ≥20 minutes (RR, 1.45 [95% CI, 1.16 to 1.81]), referral from another facility (RR, 1.46 [95% CI, 1.05 to 2.02]), and presentation to Kamuzu Central Hospital, Mangochi District Hospital, or Nkhata Bay District Hospital (RR, 1.34 [95% CI, 1.07 to 1.69]) independently increased the risk of delayed presentation. In the adult cohort, fall (RR, 1.85 [95% CI, 1.38 to 2.46]), injury over the weekend (RR, 1.80 [95% CI, 1.38 to 2.36]), estimated travel time ≥20 minutes (RR, 1.36 [95% CI, 1.03 to 1.80]), and presentation to Kamuzu Central Hospital (RR, 1.74 [95% CI, 1.30 to 2.33]) independently increased the risk of delayed presentation.

Conclusions: Delayed presentation to the hospital after a musculoskeletal injury is common in Malawi. Interventions are needed to improve access to musculoskeletal trauma care, especially for pediatric patients with tibial or fibular injuries, all patients after falls, patients injured over the weekend, and patients living far from health facilities.
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http://dx.doi.org/10.2106/JBJS.18.00516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530973PMC
May 2019

The anaesthesiologist: The unsung hero of peri-operative intensive care.

Eur J Anaesthesiol 2019 06;36(6):387-389

From the Department of Anaesthesiology and Intensive Care and Trauma Centre, Nord University Hospital, Marseille, France (CM), Division of Anaesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Italy (EDR) and Department of Anaesthesiology, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH).

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http://dx.doi.org/10.1097/EJA.0000000000000982DOI Listing
June 2019

Current use of vasopressors in septic shock.

Ann Intensive Care 2019 Jan 30;9(1):20. Epub 2019 Jan 30.

Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, University of Limoges, Limoges, France.

Background: Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use.

Methods: From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 17 questions focused on the profile of respondents, triggering factors, first choice agent, dosing, timing, targets, additional treatments, and effects of vasopressors. We investigated whether the answers complied with current guidelines. In addition, a group of 34 international ESICM experts was asked to formulate recommendations for the use of vasopressors based on 6 questions with sub-questions (total 14).

Results: A total of 839 physicians from 82 countries (65% main specialty/activity intensive care) responded. The main trigger for vasopressor use was an insufficient mean arterial pressure (MAP) response to initial fluid resuscitation (83%). The first-line vasopressor was norepinephrine (97%), targeting predominantly a MAP > 60-65 mmHg (70%), with higher targets in patients with chronic arterial hypertension (79%). The experts agreed on 10 recommendations, 9 of which were based on unanimous or strong (≥ 80%) agreement. They recommended not to delay vasopressor treatment until fluid resuscitation is completed but rather to start with norepinephrine early to achieve a target MAP of ≥ 65 mmHg.

Conclusion: Reported vasopressor use in septic shock is compliant with contemporary guidelines. Future studies should focus on individualized treatment targets including earlier use of vasopressors.
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http://dx.doi.org/10.1186/s13613-019-0498-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353977PMC
January 2019

Choice of fluids in critically ill patients.

BMC Anesthesiol 2018 12 22;18(1):200. Epub 2018 Dec 22.

Surgical Intensive Care Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.

Background: Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia.

Main Text: Until recently, because of their excellent safety profile, fluids were not considered "medications". However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions.

Conclusions: The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma).
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http://dx.doi.org/10.1186/s12871-018-0669-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303886PMC
December 2018

Current Status of Musculoskeletal Trauma Care Systems Worldwide.

J Orthop Trauma 2018 Oct;32 Suppl 7:S64-S70

Centre for Musculoskeletal Surgery Charité, Universitätsmedizin Berlin, Berlin, Germany.

Background And Rationale: Although general trauma care systems and their effects on mortality reduction have been studied, little is known of the current state of musculoskeletal trauma delivery globally, particularly in low-income (LI) and low middle-income (LMI) countries. The goal of this study is to assess and describe the development and availability of musculoskeletal trauma care delivery worldwide.

Materials & Methods: A questionnaire was developed to evaluate different characteristics of general and musculoskeletal trauma care systems, including general aspects of systems, education, access to care and pre- and posthospital care. Surgical leaders involved with musculoskeletal trauma care were contacted to participate in the survey.

Results: Of the 170 surveys sent, 95 were returned for use for the study. Nearly 30 percent of surgeons reported a formalized and coordinated trauma system in their countries. Estimates for the number of surgeons providing musculoskeletal trauma per one million inhabitants varied from 2.6 in LI countries to 58.8 in high-income countries. Worldwide, 15% of those caring for musculoskeletal trauma are fellowship trained. The survey results indicate a lack of implemented musculoskeletal trauma care guidelines across countries, with even high-income countries reporting less than 50% availability in most categories. Seventy-nine percent of the populations from LI countries were estimated to have no form of health care insurance. Formalized emergency medical services were reportedly available in only 33% and 50% of LI and LMI countries, respectively. Surgeons from LI and LMI countries responded that improvements in the availability of equipment (100%), number and locations of trauma-designated hospitals (90%), and physician training programs (88%) were necessary in their countries. The survey also revealed a general lack of resources for postoperative and rehabilitation care, irrespective of the country's income level.

Conclusion: This study addresses the current state of musculoskeletal trauma care delivery worldwide. These results indicate a greater need for trauma system development and support, from prehospital through posthospital care. Optimization of these systems can lead to better outcomes for patients after trauma. This study represents a critical first step toward better understanding the state of musculoskeletal trauma care in countries with different levels of resources, developing strategies to address deficiencies, and forming regional and international collaborations to develop musculoskeletal trauma care guidelines.
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http://dx.doi.org/10.1097/BOT.0000000000001301DOI Listing
October 2018

Essential fracture and orthopaedic equipment lists in low resource settings: consensus derived by survey of experts in Africa.

BMJ Open 2018 09 17;8(9):e023473. Epub 2018 Sep 17.

Department of Trauma and Orthopaedics, Countess of Chester Hospital NHS Foundation Trust, Chester, UK.

Introduction: Low/middle-income countries (LMICs) have a growing need for trauma and orthopaedic (T&O) surgical interventions but lack surgical resources. Part of this is due to the high amount of road traffic accidents in LMICs. We aimed to develop recommendations for an essential list of equipment for three different levels of care providers.

Methods: The Delphi method was used to achieve consensus on essential and desirable T&O equipment for LMICs. Twenty experts with T&O experience from LMICs underwent two rounds of questionnaires. Feedback was given after each round of questionnaires. The first round of questionnaire consisted of 45 items graded on a Likert scale with the second round consisting of 50 items. We used an electronic questionnaire to collect our data for three different levels of care: non-operative-based provider, specialist provider with operative fracture care and tertiary provider with operative fracture care and orthopaedics.

Results: After two rounds of questionnaires, recommendations for each level of care in LMICs included 4 essential equipment items for non-operative-based providers; 27 essential equipment items for specialist providers with operative fracture care and 46 essential equipment items for tertiary providers with operative fracture care and orthopaedic care.

Conclusion: These recommendations can facilitate in planning of appropriate equipment required in an institution which in turn has the potential to improve the capacity and quality of T&O care in LMICs. The essential equipment lists provided here can help direct where funding for equipment should be targeted. Our recommendations can help with planning and organising national T&O care in LMICs to achieve appropriate capacity at all relevant levels of care.
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http://dx.doi.org/10.1136/bmjopen-2018-023473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6144338PMC
September 2018

Morbidity and Mortality of Crystalloids Compared to Colloids in Critically Ill Surgical Patients: A Subgroup Analysis of a Randomized Trial.

Anesthesiology 2018 12;129(6):1149-1158

From the General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France (N.H., L.L., D.A.) U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France (N.H., L.L., D.A.) Department of Anesthesiology and Critical Care Medicine B, Saint Eloi Hospital, Montpellier, France (S.J.) Intensive Care Unit, Institute of Cardiology, Pitié Salpêtrière Hospital, Paris, France (J.L.T.) Anaesthesiology-Emergency-Intensive Care Unit Department, AP-HM North Hospital, Marseille, France (C.M.) Biostatistical Unit, Saint Louis Hospital, Paris, France (S.C.).

What We Already Know About This Topic: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The multicenter randomized Colloids versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was designed to test whether colloids altered mortality compared to crystalloids in the resuscitation of intensive care unit patients with hypovolemic shock. This preplanned analysis tested the same hypothesis in the subgroup of surgical patients.

Methods: The CRISTAL trial prospectively defined patients as critically ill surgical patients whenever they underwent emergency or scheduled surgery immediately before or within 24 h of intensive care unit admission and had hypovolemic shock. The primary outcome measure was death by day 28. Secondary outcome measures included death by day 90, the need for renal replacement therapy, or the need for fresh frozen plasma transfusion.

Results: There were 741 critically ill surgical patients, 356 and 385 in the crystalloid and colloid arm, respectively. Median (interquartile range) age was 66 (52 to 76) yr, and 484 (65.3%) patients were male. Surgery was unscheduled in 543 (73.3%) cases. Mortality by day 28 did not significantly differ for crystalloids 84 (23.6%) versus colloids 100 (26%; adjusted odds ratio, 0.86; 95% CI, 0.61 to 1.21; P = 0.768). Death by day 90 (111 [31.2%] vs. 122 [31.7%]; adjusted odds ratio, 0.97; 95% CI, 0.70 to 1.33; P = 0.919) did not significantly differ between groups. Renal replacement therapy was required for 42 (11.8%) patients in the crystalloids arm versus 49 (12.7%) in the colloids arm (P = 0.871).

Conclusions: The authors found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.
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http://dx.doi.org/10.1097/ALN.0000000000002413DOI Listing
December 2018

Targeting skeletal muscle tissue oxygenation (StO) in adults with severe sepsis and septic shock: a randomised controlled trial (OTO-StS Study).

BMJ Open 2018 03 19;8(3):e017581. Epub 2018 Mar 19.

Intensive Care Unit, Raymond Poincaré Hospital, Assistance Publique Hôpitaux de Paris and Laboratory of Inflammation and Infection UMR 1173, University of Versailles SQY and INSERM, Garches, France.

Objective: Evaluation of the ratio of oxyhaemoglobin to total haemoglobin in skeletal muscle (StO) using near-infrared spectroscopy may aid in the monitoring of patients with sepsis. This study assessed the benefits and risks of targeting StO in adults with severe sepsis or septic shock.

Design: A European randomised controlled trial was performed on two parallel groups.

Setting: Five intensive care units (ICU) in France, Greece, Spain and Germany were used for the study.

Participants: A total of 103 adults with severe sepsis or septic shock on ICU admission were randomised (54 subjects in the experimental arm and 49 subjects in the control arm).

Interventions: Haemodynamic management using an algorithm that was adapted from the 2004 Surviving Sepsis Campaign guidelines with (experimental arm) or without (control arm) targeting an StO value greater than 80% at a minimum of two different sites.

Outcomes: The primary outcome was a composite: 7-day all-cause mortality or worsening of organ function, defined as a positive difference in Sepsis-related Organ Failure Assessment (SOFA) score between day 7 and randomisation (ie, delta SOFA >0). Secondary endpoints: 30-day mortality, duration of mechanical ventilation and vasopressor therapy up to 30 days from randomisation.

Results: The study ended prematurely due to lack of funding after enrolment of 103/190 patients. Eighteen patients (33.3%) in the experimental arm and 14 (28.6%, P=0.67) in the control arm died or exhibited delta SOFA >0 on day 7. The mean number of days on mechanical ventilation was 12.2±10.6 in the experimental group and 7.6±7.9 in the control group (P=0.03). Thirty-one (57%) patients in the experimental arm and 14 (29%) patients in the control arm received red cells by day 7 (P=0.01).

Conclusion: Despite the limitation related to premature termination, this study provides no data to support the routine implementation of resuscitation protocols incorporating StO >80% at two or more muscle sites as a target. StO-guided therapy may be associated with prolonged use of mechanical ventilation and an increased number of red blood cell transfusions.

Trial Registration Number: NCT00167596; Results.
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http://dx.doi.org/10.1136/bmjopen-2017-017581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875667PMC
March 2018

Hydrocortisone plus Fludrocortisone for Adults with Septic Shock.

N Engl J Med 2018 Mar;378(9):809-818

From Service de Médecine Intensive et Réanimation, Hôpital Raymond Poincaré, Garches (D.A., V.M.), Laboratory of Infection and Inflammation Unité 1173, University of Versailles Saint-Quentin-en-Yvelines, INSERM, Montigny-le-Bretonneux (D.A.), Service de Pharmacologie Clinique-Centre d'Investigation Clinique (CIC) INSERM 1414, Centre Hospitalier Universitaire (CHU) de Rennes-Université de Rennes 1, Hôpital Pontchaillou, Rennes (A.R., E.B.), Service de Réanimation Médicale (C.B.-B.) and Service d'Anesthésie et des Réanimations Chirurgicales (G.D., F.C.), Hôpital Henri-Mondor (Assistance Publique-Hôpitaux de Paris [AP-HP]), Créteil, Réanimation Médicale et Toxicologique, Hôpital Lariboisière (AP-HP), Université Paris-Diderot, INSERM Unité Mixte de Recherche Scientifique (UMRS) 1144 (B. Megarbane), Réanimation Médicale-Hôpitaux Universitaires Paris Centre-Site Cochin (AP-HP) and Université Paris Descartes (A. Cariou), Médecine Intensive et Réanimation, Pôle 2i, Infection et Immunité, Hôpital Bichat-Claude Bernard, AP-HP, Infection, Antimicrobiens, Modélisation, Evolution (IAME) Unité 1137, Université Paris Diderot, INSERM (J.-F.T.), Service d'Anesthésie et Réanimations Chirurgicales, Hôpitaux Universitaires Paris Centre-Site Cochin (AP-HP) (F.B.), and Service de Réanimation Médicale, Hôpital Pitié-Salpêtrière (AP-HP), and Université Paris Sorbonne INSERM, UMRS 1166-Institute of Cardiometabolism and Nutrition (A. Combes), Paris, Service de Réanimation Médicale, Hôpital Universitaire François Mitterrand, Lipness Team, INSERM Research Center Lipids, Nutrition, Cancer-Unité Mixte de Recherche (UMR) 1231 and Laboratoire d'Excellence LipSTIC, and CIC 1432, Epidémiologie Clinique, Université de Burgundy, Dijon (J.-P.Q., A.D.), Service d'Anesthésie-Réanimation, Centre Hospitalier d'Etampes, Etampes (S.S., T.H.), Réanimation Médico-Chirurgicale, CIC INSERM 1414, Grand Hôpital de l'Est Francilien Site de Meaux, Hôpital Saint Faron, Meaux (X.F.), Service de Réanimation Médicale, CHU de Grenoble, Grenoble (C.S.), Service d'Anesthésie et de Réanimation, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Aix Marseille Université, CIC 1409, and CIC 9502, Marseille (C.M.), Service de Réanimation Polyvalente, Groupe Hospitalier Paris Saint Joseph, and Service de Réanimation Médicale, CHU de Rouen-Hôpital Charles Nicolle, Rouen (B. Misset), Service de Réanimation Polyvalente, Centre Hospitalier de Valenciennes, Valenciennes (M.A.B.), Service de Réanimation Médico-Chirurgicale, Centre Hospitalier Départemental de Vendée, Site de La Roche-sur-Yon, Les Oudairies, La Roche-sur-Yon (G. Colin), Réanimation Médicale Polyvalente, CHU Gabriel Montpied (B.S.), and Pôle de Médecine Péri-Opératoire, Génétique, Reproduction, et Développement, UMR-Centre National de la Recherche Scientifique 6293, Université Clermont-Auvergne, INSERM Unité 1103, CHU Clermont-Ferrand (J.-M.C.), Clermont-Ferrand, Service d'Anesthésie, Réanimation Chirurgicale, Hôtel Dieu-Hôpital Mère-Enfant, CHU Nantes, Laboratoire EA3826 Thérapeutiques et Expérimentales des Infections, Nantes (K.A.), Réanimation Polyvalente, Centre Hospitalier Régional Universitaire Bretonneau, Tours (E.M.), Service d'Anesthésie-Réanimation, Centre Hospitalier de Périgueux, Périgueux (L.C.), Service de Réanimation Chirurgicale, Hôpital Central, CHU de Nancy, Nancy (C.C.), Service de Réanimation Polyvalente, INSERM CIC 1435-CHU Dupuytren, Limoges (B.F.), Service Réanimation Médicale Polyvalente et Unité de Surveillance Continue, Centre Hospitalier Régional d'Orléans, Orléans (T.B.), Réanimation Chirurgicale, Département d'Anesthésie-Réanimations-Urgences, Service d'Assistance Médicale d'Urgence (SAMU) 86, Hôpital de la Miletrie, CHU, Poitiers (F.P.), Service de Réanimation Médicale, Centre Hospitalier Lyon-Sud (Hospices Civils de Lyon), Pierre-Bénite (J.B.), Service d'Anesthésie-Réanimation, Hôpital Saint Camille, Bry-sur-Marne (J.-F.L.), Réanimation Polyvalente, Hôpital Jean Verdier (AP-HP), Bondy (R.A.), Service de Réanimation Médicale, CHU Amiens-Picardie-Site Sud, Amiens (M.S.), Service de Réanimation Médicale et Maladies Infectieuses, Centre Hospitalier Tourcoing Gustave Dron, Tourcoing (O.L.), and Service de Réanimation Médicale-SAMU 25, Hôpital Jean Minjoz-CHU de Besançon, Besançon (G. Capellier) - all in France.

Background: Septic shock is characterized by dysregulation of the host response to infection, with circulatory, cellular, and metabolic abnormalities. We hypothesized that therapy with hydrocortisone plus fludrocortisone or with drotrecogin alfa (activated), which can modulate the host response, would improve the clinical outcomes of patients with septic shock.

Methods: In this multicenter, double-blind, randomized trial with a 2-by-2 factorial design, we evaluated the effect of hydrocortisone-plus-fludrocortisone therapy, drotrecogin alfa (activated), the combination of the three drugs, or their respective placebos. The primary outcome was 90-day all-cause mortality. Secondary outcomes included mortality at intensive care unit (ICU) discharge and hospital discharge and at day 28 and day 180 and the number of days alive and free of vasopressors, mechanical ventilation, or organ failure. After drotrecogin alfa (activated) was withdrawn from the market, the trial continued with a two-group parallel design. The analysis compared patients who received hydrocortisone plus fludrocortisone with those who did not (placebo group).

Results: Among the 1241 patients included in the trial, the 90-day mortality was 43.0% (264 of 614 patients) in the hydrocortisone-plus-fludrocortisone group and 49.1% (308 of 627 patients) in the placebo group (P=0.03). The relative risk of death in the hydrocortisone-plus-fludrocortisone group was 0.88 (95% confidence interval, 0.78 to 0.99). Mortality was significantly lower in the hydrocortisone-plus-fludrocortisone group than in the placebo group at ICU discharge (35.4% vs. 41.0%, P=0.04), hospital discharge (39.0% vs. 45.3%, P=0.02), and day 180 (46.6% vs. 52.5%, P=0.04) but not at day 28 (33.7% and 38.9%, respectively; P=0.06). The number of vasopressor-free days to day 28 was significantly higher in the hydrocortisone-plus-fludrocortisone group than in the placebo group (17 vs. 15 days, P<0.001), as was the number of organ-failure-free days (14 vs. 12 days, P=0.003). The number of ventilator-free days was similar in the two groups (11 days in the hydrocortisone-plus-fludrocortisone group and 10 in the placebo group, P=0.07). The rate of serious adverse events did not differ significantly between the two groups, but hyperglycemia was more common in hydrocortisone-plus-fludrocortisone group.

Conclusions: In this trial involving patients with septic shock, 90-day all-cause mortality was lower among those who received hydrocortisone plus fludrocortisone than among those who received placebo. (Funded by Programme Hospitalier de Recherche Clinique 2007 of the French Ministry of Social Affairs and Health; APROCCHSS ClinicalTrials.gov number, NCT00625209 .).
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http://dx.doi.org/10.1056/NEJMoa1705716DOI Listing
March 2018

Haemodynamic response to crystalloids or colloids in shock: an exploratory subgroup analysis of a randomised controlled trial.

BMJ Open 2017 Oct 6;7(10):e016736. Epub 2017 Oct 6.

General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.

Objective: To compare the haemodynamic effect of crystalloids and colloids during acute severe hypovolaemic shock.

Design: Exploratory subgroup analysis of a multicentre randomised controlled trial (Colloids Versus Crystalloids for the Resuscitation of the Critically Ill, CRISTAL, ClinicalTrials.gov NCT00318942).

Setting: CRISTAL was conducted in intensive care units in Europe, North Africa and Canada.

Participants: Current analysis included all patients who had a pulmonary artery catheter in place at randomisation. 220 patients (117 received crystalloids vs 103 colloids) underwent pulmonary artery catheterisation.

Intervention: Crystalloids versus colloids for fluid resuscitation in hypovolaemic shock.

Outcome Measures: Haemodynamic data were collected at the time of randomisation and subsequently on days 1, 2, 3, 4, 5, 6 and 7.

Results: Median cumulative volume of fluid administered during the first 7 days was higher in the crystalloids group than in the colloids group (3500 (2000-6000) vs 2500 (1000-4000) mL, p=0.01). Patients in the colloids arm exhibited a lower heart rate over time compared with those allocated to the crystalloids arm (p=0.014). There was no significant difference in Cardiac Index (p=0.053), mean blood pressure (p=0.4), arterial lactates (p=0.9) or global Sequential Organ Failure Assessment score (p=0.3) over time between arms.

Conclusions: During acute severe hypovolaemic shock, patients monitored by a pulmonary artery catheter achieved broadly similar haemodynamic outcomes, using lower volumes of colloids than crystalloids. The heart rate was lower in the colloids arm.
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http://dx.doi.org/10.1136/bmjopen-2017-016736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640079PMC
October 2017

Implementation of an electronic checklist in the ICU: Association with improved outcomes.

Anaesth Crit Care Pain Med 2018 Feb 10;37(1):25-33. Epub 2017 Jul 10.

Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France. Electronic address:

Objective: To assess the impact of an electronic checklist during the morning rounds on ventilator-associated pneumonia (VAP) in the intensive care unit (ICU).

Patients And Methods: We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist.

Results: We analysed 1711 patients (before group, n=761; after group, n=950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p<0.001). In propensity-score matched analysis (n=742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.27-0.53). The after group showed increases in ICU-free days (OR=1.05; 95% CI=1.04-1.07) and mechanical ventilation-free days (OR=1.03; 95% CI=1.01-1.04).

Conclusion: In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations.
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http://dx.doi.org/10.1016/j.accpm.2017.04.006DOI Listing
February 2018

Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance).

World J Surg 2017 10;41(10):2426-2434

The College of Surgeons of East, Central and Southern Africa, Arusha, Tanzania.

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.
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http://dx.doi.org/10.1007/s00268-017-4028-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5596034PMC
October 2017

Collaborative approach of individual participant data of prospective studies of de-escalation in non-immunosuppressed critically ill patients with sepsis.

Expert Rev Clin Pharmacol 2017 Apr 2;10(4):457-465. Epub 2017 Mar 2.

d Trinity College, St James's University Hospital, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO) , Dublin , Ireland.

Background: There is a concern to conduct de-escalation in very sick patients.

Aims: To determine if de-escalation is feasible in ICU settings.

Methods: We performed a metaanalysis of published studies conducted comparing de-escalation (defined by withdrawal of at least one antimicrobial empirically prescribed, switch to a new antimicrobial with narrower spectrum and withdrawal of at least one antimicrobial plus change of another drug to a new one with narrower spectrum) in non-immunocompromised patients with sepsis admitted to ICU.

Results: Eight hundred and seventeen patients with severe sepsis or septic shock were evaluated. De-escalation was applied in 274 patients (33.5%). We found no differences in hospital long of stay between de-escalation group compared to those who did not receive it. We also found significant lower hospital mortality in de-escalation group as compared with no modification group in front of the others (25.9 vs. 43.1%; p < 0.001). Taking into account the etiology of infection, in both gram negative and gram positives microorganisms, de-escalation strategy was assessed as a good prognosis factor for mortality in the adjusted multivariate analysis (OR 0.41; 95% CI 0.22-0.74 and OR 0.33; 95% CI 0.15-0.70 respectively) whereas SOFA score along with age were found as a factors independently associated with a worse clinical outcome (OR 1.23; 95% CI 1.12-1.35 and OR 1.02; 95% CI 1.01-1.04 respectively).

Conclusions: In our study there was an independent association of de-escalation and decrease mortality rate.
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http://dx.doi.org/10.1080/17512433.2017.1293520DOI Listing
April 2017

Antibiotic therapy in the critically ill - expert opinion of the Intensive Care Medicine Scientific Subcommittee of the European Society of Anaesthesiology.

Eur J Anaesthesiol 2017 Apr;34(4):215-220

From the Multidisciplinary Intensive Care, St James's University Hospital (IML); Department of Clinical Medicine, Trinity College, Dublin, Ireland (IML); Anaesthesia and Intensive Care Unit and Trauma Centre, Aix Marseille University, Nord Hospital, Assistance Publique Hôpitaux de Marseille, APHM, Marseille, France (ML, CM); Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary (KM); General Intensive Care Unit, Shaare Zedek Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel (SE).

Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.
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http://dx.doi.org/10.1097/EJA.0000000000000595DOI Listing
April 2017

Postoperative analgesia after caesarean section with transversus abdominis plane block or continuous infiltration wound catheter: A randomized clinical trial. TAP vs. infiltration after caesarean section.

Anaesth Crit Care Pain Med 2016 Dec 23;35(6):401-406. Epub 2016 Jun 23.

Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France; Centre d'Investigation Clinique 1409, Aix Marseille Université, Assistance Publique-Hôpitaux de Marseille, Marseille, France. Electronic address:

Objective: Single shot transversus abdominis plane (TAP) block and continuous local anesthetic infiltration wound catheter (CLAIWC) decreased the morphine consumption after caesarean section. The aim of this study was to compare the analgesic efficacy of CLAIWC and ultrasound-guided TAP block.

Method: Sixty patients undergoing caesarean section were prospectively randomized. After the caesarean section, the postoperative analgesia was randomized to either a CLAIWC localized below the fascia with an elastomeric pump for 48hours or a bilateral ultrasound-guided TAP block with injection of ropivacaine. Every patient had a morphine pump patient-controlled analgesia. The primary outcome was the morphine consumption during the first 48hours. Secondary outcomes were pain score levels, adverse effects of opioids, and patient satisfaction. Variables were collected during 48hours after the caesarean section.

Results: Median cumulative 48-hour morphine consumption was 17 [8-51] mg in the TAP group versus 21 [7-34] mg in the CLAIWC group (P=0.3). We did not find a difference between the groups regarding pain, side effects and satisfaction scores.

Conclusion: As part of a multimodal analgesic regimen, there is no significant difference between the TAP block and CLAIWC for postoperative analgesia after a caesarean section.
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http://dx.doi.org/10.1016/j.accpm.2016.02.006DOI Listing
December 2016

Lung ultrasonography for assessment of oxygenation response to prone position ventilation in ARDS.

Intensive Care Med 2016 Oct 20;42(10):1546-1556. Epub 2016 Jun 20.

Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Chemin des Bourrely, 13015, Marseille, France.

Purpose: Prone position (PP) improves oxygenation and outcome of acute respiratory distress syndrome (ARDS) patients with a PaO2/FiO2 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 PaCO2 change was found according to oxygenation response or lung morphology.

Conclusions: In ARDS patients with a PaO2/FiO2 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.
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http://dx.doi.org/10.1007/s00134-016-4411-7DOI Listing
October 2016

Design and conduct of the activated protein C and corticosteroids for human septic shock (APROCCHSS) trial.

Ann Intensive Care 2016 Dec 6;6(1):43. Epub 2016 May 6.

Service de Pharmacologie, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université de Rennes 1, Rennes, France.

Background: We aimed at assessing the benefit-to-risk ratio of activated protein C (drotrecogin-alfa activated, DAA) and corticosteroids, given alone or in combination, in patients with septic shock.

Methods: We implemented an investigator-led, publicly funded, multicenter, randomized according to a 2 × 2 factorial design, placebo-controlled, double-blind trial in four parallel groups in which adults with persistent septic shock and no contraindication to DAA were assigned to either DAA alone (24 mg/kg/h for 96 h), or hydrocortisone (50 mg intravenous bolus q6 for 7 days) and fludrocortisone (50 µg once daily through the nasogastric tube for 7 days) alone, or their respective combinations, or their respective placebos. Primary endpoint was 90-day mortality rate. Follow-up duration was 6 months. Statistical analysis was planned to be performed in intent-to-treat once after all participants completed 180-day follow-up and according to the 2 × 2 factorial design.

Results: The first patient was recruited in September 2008. The trial was suspended on October 25, 2011, owing to the withdrawal from the market of DAA. At this time, 411 patients had been enrolled. On May 17, 2012, the continuation of the trial on two parallel groups was approved by all legal authorities with the aim of investigating the benefit-to-risk ratio of corticosteroids. On June 30, 2014, the trial was suspended again by the study sponsor upon request of the independent data and safety monitoring board. Recruitment restarted on October 7, 2014, after any safety concern was ruled out. Finally, the trial was completed on June 23, 2015, with the recruitment of 1241 patients.

Conclusions: This report details the design, statistical plan and conduct of a randomized controlled trial of hydrocortisone and fludrocortisone in septic shock. Trial registration The trial was registered at ClinicalTrials.gov under NCT00625209.
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http://dx.doi.org/10.1186/s13613-016-0147-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859323PMC
December 2016

Antimicrobial therapy in patients with septic shock.

Presse Med 2016 Apr 6;45(4 Pt 2):e111-7. Epub 2016 Apr 6.

Aix Marseille université, Assistance publique-Hôpitaux de Marseille, hôpital Nord, service d'anesthésie et de réanimation, 13015 Marseille, France. Electronic address:

Providing antibiotics is a life-saving intervention in patients with septic shock. Cultures as clinically appropriate before antimicrobial therapy are required. Guidelines recommend providing broad-spectrum antibiotics within the first hour after recognition of shock. The site of infection, the patient's history and clinical status, and the local ecology all affect the choice of empirical treatment. The appropriateness of this choice is an important determinant of patient outcome. At 48-96h, the antimicrobial treatment should be systematically reassessed based on the clinical course and culture results. Cessation, de-escalation, continuation, or escalation are discussed according to these variables. Unnecessary treatment should be avoided to reduce the emergence of multidrug resistant pathogens.
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http://dx.doi.org/10.1016/j.lpm.2016.03.006DOI Listing
April 2016

Emerging role of Raoultella ornithinolytica in human infections: a series of cases and review of the literature.

Int J Infect Dis 2016 Apr 24;45:65-71. Epub 2016 Feb 24.

Centre de Référence des Infections Ostéo-Articulaires (CRIOAC) Interrégional Sud Méditerranée, Service des Maladies Infectieuses, Hôpital de la Conception, 147 boulevard Baille, 13005 Marseille, France; Aix-Marseille Université, Faculté de Médecine, Marseille, France.

Background: Raoultella ornithinolytica is known to inhabit aquatic environments. The clinical features and outcomes of human infections caused by R. ornithinolytica have been reported for only a limited number of cases.

Methods: A retrospective study of cases of infection caused by R. ornithinolytica managed at four university hospital centres during the period before and after the introduction of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) was performed. The aim was to describe the clinical and microbiological characteristics, treatments, and outcomes.

Results: Among 187 R. ornithinolytica isolates identified for which clinical information was available, 71 were considered colonizers and 116 were pathogenic. A total of 112 cases of R. ornithinolytica infection were identified. Urinary tract infections, gastrointestinal infections, wound and skin infections, and bacteraemia were observed in 36%, 14%, 13%, and 5% of cases, respectively. Associated infections that have been poorly reported, such as respiratory infections, i.e. pneumonia and pleural effusion, were observed in 24% of cases. Additional diseases reported here for the first time included osteomyelitis, meningitis, cerebral abscess, mediastinitis, pericarditis, conjunctivitis, and otitis. The proportion of R. ornithinolytica isolates resistant to antibiotics was found to be relatively high: 4% of isolates were resistant to ceftriaxone, 6% to quinolones, and 13% to co-trimoxazole. The mortality rate related to infection was 5%.

Conclusions: R. ornithinolytica is an underreported, emerging hospital-acquired infection and is particularly associated with invasive procedures. R. ornithinolytica should never be considered simply a saprophytic bacterium that occasionally contaminates bronchial lavage or other deep respiratory samples or surgical sites. Physicians should be aware of the high rates of antimicrobial resistance of R. ornithinolytica isolates so that immediate broad-spectrum antibiotic treatment can be established before accurate microbiological results are obtained.
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http://dx.doi.org/10.1016/j.ijid.2016.02.014DOI Listing
April 2016

Reduction of self-perceived discomforts in critically ill patients in French intensive care units: study protocol for a cluster-randomized controlled trial.

Trials 2016 Feb 16;17:87. Epub 2016 Feb 16.

EA3279 Self-perceived Health Assessment Research Unit Aix-Marseille University, Marseille, France.

Background: It is now well documented that critically ill patients are exposed to stressful conditions and experience discomforts from multiple sources. Improved identification of the discomforts of patients in intensive care units (ICUs) may have implications for managing their care, including consideration of ethical issues, and may assist clinicians in choosing the most appropriate interventions. The primary objective of this study was to assess the effectiveness of a multicomponent program of discomfort reduction in critically ill patients. The secondary objectives were to assess the sustainability of the impact of the program and the potential seasonality effect.

Methods/design: We conducted a multicenter, cluster-randomized, controlled, single (patient)-blind study involving 34 French adult ICUs. The experimental intervention was a 6-month period during which the multicomponent program was implemented in the ICU and included the following steps: identification of discomforts, immediate feedback to the healthcare team, and implementation of targeted interventions. The control intervention was a 6-month period during which any program was implemented. The primary endpoint was the monthly overall score of self-reported discomfort from the French questionnaire on discomforts in ICU patients (IPREA). The secondary endpoints were the scores of the discomfort items of IPREA. The sample size was 660 individuals to obtain 80% power to detect a 25% difference in the overall discomfort score of IPREA between the two groups (design effect: 2.9).

Discussion: The results of this cluster-randomized controlled study are expected to confirm that a multicomponent program of discomfort reduction may be a new strategy in the management of care for critically ill patients.

Trial Registration: ClinicalTrials.gov NCT02442934, registered 11 May 2015.
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http://dx.doi.org/10.1186/s13063-016-1211-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754872PMC
February 2016

SEPsis REcognition and MAnagement (SEPREMA survey).

Intensive Care Med 2016 Mar 11;42(3):477-478. Epub 2016 Jan 11.

Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

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http://dx.doi.org/10.1007/s00134-015-4201-7DOI Listing
March 2016

Night shift decreases cognitive performance of ICU physicians.

Intensive Care Med 2016 Mar 10;42(3):393-400. Epub 2015 Nov 10.

Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Chemin des Bourrely, 13015, Marseille, France.

Background: The relationship between tiredness and the risk of medical errors is now commonly accepted. The main objective of this study was to assess the impact of an intensive care unit (ICU) night shift on the cognitive performance of a group of intensivists. The influence of professional experience and the amount of sleep on cognitive performance was also investigated.

Methods: A total of 51 intensivists from three ICUs (24 seniors and 27 residents) were included. The study participants were evaluated after a night of rest and after a night shift according to a randomized order. Four cognitive skills were tested according to the Wechsler Adult Intelligence Scale and the Wisconsin Card Sorting Test.

Results: All cognitive abilities worsened after a night shift: working memory capacity (11.3 ± 0.3 vs. 9.4 ± 0.3; p < 0.001), speed of processing information (13.5 ± 0.4 vs. 10.9 ± 0.3; p < 0.001), perceptual reasoning (10.6 ± 0.3 vs. 9.3 ± 0.3; p < 0.002), and cognitive flexibility (41.2 ± 1.2 vs. 44.2 ± 1.3; p = 0.063). There was no significant difference in terms of level of cognitive impairment between the residents and ICU physicians. Only cognitive flexibility appeared to be restored after 2 h of sleep. The other three cognitive skills were altered, regardless of the amount of sleep during the night shift.

Conclusions: The cognitive abilities of intensivists were significantly altered following a night shift in the ICU, regardless of either the amount of professional experience or the duration of sleep during the shift. The consequences for patients' safety and physicians' health should be further evaluated.
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http://dx.doi.org/10.1007/s00134-015-4115-4DOI Listing
March 2016

Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort.

J Antimicrob Chemother 2016 Jan 3;71(1):196-207. Epub 2015 Oct 3.

Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia

Objectives: We utilized the database of the Defining Antibiotic Levels in Intensive care unit patients (DALI) study to statistically compare the pharmacokinetic/pharmacodynamic and clinical outcomes between prolonged-infusion and intermittent-bolus dosing of piperacillin/tazobactam and meropenem in critically ill patients using inclusion criteria similar to those used in previous prospective studies.

Methods: This was a post hoc analysis of a prospective, multicentre pharmacokinetic point-prevalence study (DALI), which recruited a large cohort of critically ill patients from 68 ICUs across 10 countries.

Results: Of the 211 patients receiving piperacillin/tazobactam and meropenem in the DALI study, 182 met inclusion criteria. Overall, 89.0% (162/182) of patients achieved the most conservative target of 50% fT>MIC (time over which unbound or free drug concentration remains above the MIC). Decreasing creatinine clearance and the use of prolonged infusion significantly increased the PTA for most pharmacokinetic/pharmacodynamic targets. In the subgroup of patients who had respiratory infection, patients receiving β-lactams via prolonged infusion demonstrated significantly better 30 day survival when compared with intermittent-bolus patients [86.2% (25/29) versus 56.7% (17/30); P = 0.012]. Additionally, in patients with a SOFA score of ≥9, administration by prolonged infusion compared with intermittent-bolus dosing demonstrated significantly better clinical cure [73.3% (11/15) versus 35.0% (7/20); P = 0.035] and survival rates [73.3% (11/15) versus 25.0% (5/20); P = 0.025].

Conclusions: Analysis of this large dataset has provided additional data on the niche benefits of administration of piperacillin/tazobactam and meropenem by prolonged infusion in critically ill patients, particularly for patients with respiratory infections.
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http://dx.doi.org/10.1093/jac/dkv288DOI Listing
January 2016