Publications by authors named "François Antonini"

49 Publications

Left ventricular longitudinal strain variations assessed by speckle-tracking echocardiography after a passive leg raising maneuver in patients with acute circulatory failure to predict fluid responsiveness: A prospective, observational study.

PLoS One 2021 30;16(9):e0257737. Epub 2021 Sep 30.

Department of Anesthesiology and Intensive Care Unit, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France.

Background: An association was reported between the left ventricular longitudinal strain (LV-LS) and preload. LV-LS reflects the left cardiac function curve as it is the ratio of shortening over diastolic dimension. The aim of this study was to determine the sensitivity and specificity of LV-LS variations after a passive leg raising (PLR) maneuver to predict fluid responsiveness in intensive care unit (ICU) patients with acute circulatory failure (ACF).

Methods: Patients with ACF were prospectively included. Preload-dependency was defined as a velocity time integral (VTI) variation greater than 10% between baseline (T0) and PLR (T1), distinguishing the preload-dependent (PLD+) group and the preload-independent (PLD-) group. A 7-cycles, 4-chamber echocardiography loop was registered at T0 and T1, and strain analysis was performed off-line by a blind clinician. A general linear model for repeated measures was used to compare the LV-LS variation (T0 to T1) between the two groups.

Results: From June 2018 to August 2019, 60 patients (PLD+ = 33, PLD- = 27) were consecutively enrolled. The VTI variations after PLR were +21% (±8) in the PLD+ group and -1% (±7) in the PLD- group (p<0.01). Mean baseline LV-LS was -11.3% (±4.2) in the PLD+ group and -13.0% (±4.2) in the PLD- group (p = 0.12). LV-LS increased in the whole population after PLR +16.0% (±4.0) (p = 0.04). The LV-LS variations after PLR were +19.0% (±31) (p = 0.05) in the PLD+ group and +11.0% (±38) (p = 0.25) in the PLD- group, with no significant difference between the two groups (p = 0.08). The area under the curve for the LV-LS variations between T0 and T1 was 0.63 [0.48-0.77].

Conclusion: Our study confirms that LV-LS is load-dependent; however, the variations in LV-LS after PLR is not a discriminating criterion to predict fluid responsiveness of ICU patients with ACF in this cohort.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257737PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483378PMC
November 2021

Beta-lactam allergy labeling in intensive care units: An observational, retrospective study.

Medicine (Baltimore) 2021 Jul;100(27):e26494

Aix Marseille Université, School of Medicine - La Timone Medical Campus, EA 3279, CEReSS - Health Service Research and Quality of Life Center.

Abstract: This retrospective study aimed to describe the association between the "β-lactam allergy" labeling (BLAL) and the outcomes of a cohort of intensive care unit (ICU) patients.Retrospective cohort study.Seven ICU of the Aix Marseille University Hospitals from Marseille in France.We collected the uses of the label "β-lactam allergy" in the electronic medical files of patients aged 18 years or more who required more than 48 hours in the ICU with mechanical ventilation and/or vasopressors admitted to 7 ICUs of a single institution.We retrospectively compared the patients with this labeling (BLAL group) with those without this labeling (control group).The primary outcome was the duration of ICU stay. Among the 7146 patients included in the analysis, 440 and 6706 patients were classified in the BLAL group and the control group, respectively. The prevalence of BLAL was 6.2%. In univariate and multivariate analyses, BLAL was weakly or not associated with the duration of ICU and hospital stays (respectively, 6 [3-14] vs 6 [3-14] days, standardized beta -0.09, P = .046; and 18 [10-29] vs 15 [8-28] days, standardized beta -0.09, P = .344). In multivariate analysis, the ICU and 28-day mortality rates were both lower in the BLAL group than in the control group (aOR 0.79 95% CI [0.64-0.98] P = .032 and 0.79 [0.63-0.99] P = .042). Antibiotic use differed between the 2 groups, but the outcomes were similar in the subgroups of septic patients in the BLAL group and the control group.In our cohort, the labeling of a β-lactam allergy was not associated with prolonged ICU and hospital stays. An association was found between the labeling of a β-lactam allergy and lower ICU and 28-day mortality rates.Trial registration: Retrospectively registered.
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http://dx.doi.org/10.1097/MD.0000000000026494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270612PMC
July 2021

Management of SARS-CoV-2 pneumonia in intensive care unit: An observational retrospective study comparing two bundles.

J Crit Care 2021 10 29;65:200-204. Epub 2021 Jun 29.

Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Department of Anesthesiology and Intensive Care, Hôpital Nord, Marseille 13015, France.

Purpose: To compare the effects of two therapeutic bundles of management in SARS-CoV2 ICU patients.

Materials And Methods: Our retrospective, observational study was performed in a university ICU from March to June 2020 (first wave) and from September 2020 to January 2021 (second wave). In first wave, patients received bundle 1 including early invasive ventilation, hydroxychloroquine, cefotaxime and azithromycin. In second wave, bundle 2 included non-invasive oxygenation support and dexamethasone. The main outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay, ICU supportive therapies, viral clearance and antimicrobial resistance emergence.

Results: 129 patients with SARS-CoV-2 pneumonia were admitted to our ICU. Thirty-five were treated according to bundle 1 and 76 to bundle 2. In-hospital mortality was similar in the two groups (23%, p = 1). The hospital (p = 0.003) and ICU (p = 0.01) length of stay and ventilator-free days at 28 days (p = 0.03) were significantly reduced in bundle 2. Increasing age, vasopressor use and PaO/FiO ratio < 125 were associated with in-hospital mortality.

Conclusion: Within the limitations of our study, changes in therapeutic bundles for SARS-Cov-2 ICU patients might have no effect on in-hospital mortality but were associated with less exposure to mechanical ventilation and reduced hospital length of stay.
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http://dx.doi.org/10.1016/j.jcrc.2021.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238648PMC
October 2021

Exacerbation of circadian rhythms of core body temperature and sepsis in trauma patients.

J Crit Care 2020 12 16;60:23-26. Epub 2020 Jul 16.

Aix Marseille Université, Institut de Recherche pour le Développement, Assistance Publique-Hôpitaux de Marseille, Microbes Evolution Phylogénie et Infections (MEPHI), Institut Hospitalo-Universitaire (IHU)-Méditerranée Infection, Marseille, France.

Purpose: This study aimed to describe by mathematical modeling an accurate course of core body temperature (CBT) in severe trauma patients and its relation to sepsis.

Methods: In a cohort of severe trauma, the CBT measurements were collected for 24 h on day 2 after admission and rhythmicity assessed by Fourier transform and Cosinor analysis to describe circadian features (frequency and amplitude). CBT was compared between patients who developed sepsis or not during the early ICU stay.

Results: 33 patients were included in this analysis. 24 patients (73%) had a predominant rhythm of 24 h (period). The main period was lower in the 9 remaining patients (6 of 12 h, 1 of 8 h, and 2 of 6 h). Other significant frequencies of oscillation (second and third frequencies) were found, which showed an association of several well-marked rhythms. Patients with sepsis (n = 12) had a significantly higher level of CBT, but also more intense rhythms and higher amplitudes of CBT.

Conclusion: Trauma patients exhibit complex temperature circadian rhythms. Early exacerbation of the temperature rhythmicity (in frequency and amplitude) is associated with the development of sepsis. This observation accentuates the concept of circadian disruption and sepsis in ICU patients.
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http://dx.doi.org/10.1016/j.jcrc.2020.07.010DOI Listing
December 2020

Decreased duration of intravenous cephalosporins in intensive care unit patients with selective digestive decontamination: a retrospective before-and-after study.

Eur J Clin Microbiol Infect Dis 2020 Nov 2;39(11):2115-2120. Epub 2020 Jul 2.

Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Service d'anesthésie et de réanimation, Marseille, France.

Selective digestive decontamination (SDD) reduces the rate of infection and improves the outcomes of patients admitted to an intensive care unit (ICU). A risk associated with its use is the development of multi-drug-resistant organisms. We hypothesized that a 1-day reduction in systemic antimicrobial exposure in the SDD regimen would not affect the outcomes of our patients. In this before-and-after study design, 199 patients and 248 patients were included in a 3-day SDD group and a 2-day SDD group, respectively. The rates of hospital-acquired pneumonia and ICU infections were similar in both groups. The rates of bloodstream infection and bacteriuria were significantly lower in the 2-day SDD group than in the 3-day SDD group. Compared with the patients in the 3-day group, the patients in the 2-day SDD group received fewer antibiotics and less exposure to mechanical ventilation, and they used fewer ICU resources. The rates of ICU mortality and 28-day mortality were similar in both groups. The incidence of multi-drug-resistant organisms was similar in both groups. Within the limitations inherent to our study design, reducing the exposure of prophylactic systemic antibiotics in the SDD setting from 3 days to 2 days was not associated with impaired outcomes. Future randomized controlled trials should be conducted to test this hypothesis and investigate the effects on the development of multi-drug resistant organisms.
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http://dx.doi.org/10.1007/s10096-020-03966-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330883PMC
November 2020

Lung Ultrasound Findings in the Postanesthesia Care Unit Are Associated With Outcome After Major Surgery: A Prospective Observational Study in a High-Risk Cohort.

Anesth Analg 2021 01;132(1):172-181

Department of Anesthesia and Intensive Care Medicine, and Centre d 'Investigation Clinique, Nord Hospital, Aix Marseille University, APHM, Marseille, France.

Background: Postoperative pulmonary complications are associated with increased morbidity. Identifying patients at higher risk for such complications may allow preemptive treatment.

Methods: Patients with an American Society of Anesthesiologists (ASA) score >1 and who were scheduled for major surgery of >2 hours were enrolled in a single-center prospective study. After extubation, lung ultrasound was performed after a median time of 60 minutes by 2 certified anesthesiologists in the postanesthesia care unit after a standardized tracheal extubation. Postoperative pulmonary complications occurring within 8 postoperative days were recorded. The association between lung ultrasound findings and postoperative pulmonary complications was analyzed using logistic regression models.

Results: Among the 327 patients included, 69 (19%) developed postoperative pulmonary complications. The lung ultrasound score was higher in the patients who developed postoperative pulmonary complications (12 [7-18] vs 8 [4-12]; P < .001). The odds ratio for pulmonary complications in patients who had a pleural effusion detected by lung ultrasound was 3.7 (95% confidence interval, 1.2-11.7). The hospital death rate was also higher in patients with pleural effusions (22% vs 1.3%; P < .001). Patients with pulmonary consolidations on lung ultrasound had a higher risk of postoperative mechanical ventilation (17% vs 5.1%; P = .001). In all patients, the area under the curve for predicting postoperative pulmonary complications was 0.64 (95% confidence interval, 0.57-0.71).

Conclusions: When lung ultrasound is performed precociously <2 hours after extubation, detection of immediate postoperative alveolar consolidation and pleural effusion by lung ultrasound is associated with postoperative pulmonary complications and morbi-mortality. Further study is needed to determine the effect of ultrasound-guided intervention for patients at high risk of postoperative pulmonary complications.
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http://dx.doi.org/10.1213/ANE.0000000000004755DOI Listing
January 2021

Circadian disruption of core body temperature in trauma patients: a single-center retrospective observational study.

J Intensive Care 2020 6;8. Epub 2020 Jan 6.

Service d'Anesthésie et de Réanimation, APHM, Hôpital Nord, Aix Marseille Université, Chemin des Bourrely, 13915 Marseille, France.

Background: Circadian clock alterations were poorly reported in trauma patients, although they have a critical role in human physiology. Core body temperature is a clinical variable regulated by the circadian clock. Our objective was to identify the circadian temperature disruption in trauma patients and to determine whether these disruptions were associated with the 28-day mortality rate.

Methods: A retrospective and observational single-center cohort study was conducted. All adult severe trauma patients admitted to the intensive care unit of Aix Marseille University, North Hospital, from November 2013 to February 2018, were evaluated. The variations of core body temperature for each patient were analyzed between days 2 and 3 after intensive care unit admission. Core body temperature variations were defined by three parameters: mesor, amplitude, and period. A logistic regression model was used to determine the variables influencing these three parameters. A survival analysis was performed assessing the association between core body temperature rhythm disruption and 28-day mortality rate. A post hoc subgroup analysis focused on the patients with head trauma.

Results: Among the 1584 screened patients, 248 were included in this study. The period differed from 24 h in 177 (71%) patients. The mesor value (°C) was associated with body mass index and ketamine use. Amplitude (°C) was associated with ketamine use only. The 28-day mortality rate was 18%. For all trauma patients, age, body mass index, intracranial hypertension, and amplitude were independent risk factors. The patients with a mesor value < 36.9 °C ( < 0.001) and an amplitude > 0.6 °C ( < 0.001) had a higher 28-day mortality rate. Among the patients with head trauma, mesor and amplitude were identified as independent risk factors (HR = 0.40, 95% CI [0.23-0.70],  = 0.001 and HR = 4.73, 95% CI [1.38-16.22],  = 0.01).

Conclusions: Our results highlight an association between core body temperature circadian alteration and 28-day mortality rate. This association was more pronounced in the head trauma patients than in the non-head trauma patients. Further studies are needed to show a causal link and consider possible interventions.
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http://dx.doi.org/10.1186/s40560-019-0425-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945723PMC
January 2020

Incidental Finding of Thrombus by Ultrasonography in a Trauma Patient with an Intravascular Cooling Device.

Ther Hypothermia Temp Manag 2019 Dec 22;9(4):265-267. Epub 2019 Aug 22.

Departement d'Anesthésie Réanimation, Hôpital Nord, Marseille, France.

In patients with traumatic brain injury, coagulation disorders may both cause bleeding and thrombosis. The addition of risk factors, including invasive devices, probably increases the risk of complications. The benefit of using intravascular cooling device should be balanced by the risk to generate thrombosis. The use of routine ultrasound was associated with an incidental diagnosis of thrombus, accelerating the onset of curative anticoagulation.
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http://dx.doi.org/10.1089/ther.2018.0047DOI Listing
December 2019

Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: Impact on the management of 756 patients.

Injury 2018 Oct 8;49(10):1774-1780. Epub 2018 Jul 8.

Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France; Aix-Marseille University, Marseille, France; Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, UMR 63, Marseille, France.

Background: Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe trauma patients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings.

Methods: Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports.

Results: Among the 1315 trauma patients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and underwent an inappropriate immediate laparotomy.

Conclusions: In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies.
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http://dx.doi.org/10.1016/j.injury.2018.07.002DOI Listing
October 2018

Risk factors for death in septic shock: A retrospective cohort study comparing trauma and non-trauma patients.

Medicine (Baltimore) 2017 Dec;96(50):e9241

Aix Marseille Université, Service d'anesthésie et de réanimation, Hôpital Nord, AP-HM Unité d'Aide Méthodologique à la Recherche Clinique et Epidémiologique, Aix Marseille Université, Marseille, France.

The aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P < 0.0). A sequential organ failure assessment score above 12 (odds ratio [OR]: 6.8; 95% confident interval (CI) [1.3-37], P = 0.025) was independently associated with septic shock associated-mortality, whereas severe trauma was a protective factor (OR: 0.26; 95% CI [0.08-0.78], P = 0.01). From these independent risk factors, we determined the probability of septic shock associated-mortality. The receiver-operating characteristics curve has an area under the curve at 0.76 with sensitivity of 55% and specificity of 86%. Trauma appears as a protective factor, whereas the severity of organ failure has a major role in the mortality of septic shock. However, because of the study's design, unmeasured confounding factors should be taken into account in our findings.
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http://dx.doi.org/10.1097/MD.0000000000009241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815768PMC
December 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

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

Two-dimensional-strain echocardiography in intensive care unit patients: A prospective, observational study.

J Clin Ultrasound 2016 Jul 4;44(6):368-74. Epub 2016 Mar 4.

Service d'anesthésie et de réanimation, hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France.

Purpose: Two-dimensional-strain echocardiography (2D-strain) is a promising technique for the early detection of myocardial dysfunction. Our study was aimed to assess its feasibility in the intensive care unit (ICU). Our secondary goal was to determine if 2D-strain could predict the patient's outcome.

Methods: Conventional echocardiography and 2D-strain were performed on 64 consecutive patients admitted to our ICU. Using 2D-strain, the longitudinal deformation of the left ventricle was assessed. Feasibility of 2D-strain, diagnosis performance, and 28-day mortality prediction were determined.

Results: 2D-strain measurements could be performed in 77% of our patients. All 2D-strain variables related to ventricular performance were significantly impaired in the patients who died compared with those who survived. Strain global medium was the only independent echocardiographic variable predictor of 28-day mortality rate (odds ratio 0.60; 95% confidence interval 0.43-0.80, p = 0.002).

Conclusions: 2D-strain measurement is feasible in ICU patients, enabling identifying early left ventricle dysfunction. Strain global medium is an independent predictor of 28-day mortality. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:368-374, 2016.
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http://dx.doi.org/10.1002/jcu.22349DOI Listing
July 2016

Point-of-care ultrasound in intensive care units: assessment of 1073 procedures in a multicentric, prospective, observational study.

Intensive Care Med 2015 Sep 10;41(9):1638-47. Epub 2015 Jul 10.

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

Objective: To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU).

Background: POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown.

Methods: Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified.

Results: Among 1954 patients hospitalized during the study period, 1073 (55%) POCUS/day were performed in 709 (36%) patients. POCUS served for diagnostic assessment in 932 (87%) cases and procedural guidance in 141 (13%) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16% of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69%, respectively. Ultrasound guidance was used in 54 and 15% of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts.

Conclusions: With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.
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http://dx.doi.org/10.1007/s00134-015-3952-5DOI Listing
September 2015

NOREPINEPHRINE: NOT TOO MUCH, TOO LONG.

Shock 2015 Oct;44(4):305-9

Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, and Aix Marseille Université, Marseille, France.

The study was designed to assess whether high dosages of norepinephrine are associated with increased death rate and to determine the dosage of norepinephrine associated with an intensive care unit (ICU) death rate greater than 90%. We conducted a retrospective, noninterventional, observational study in a single ICU (15 beds) of an academic hospital. From January 2009 to May 2013, data of all patients with a diagnosis of septic shock were extracted from our database. Data were collected at the time of the admission in ICU, at the onset of septic shock, and when the maximal posology of norepinephrine was reached. Mortality was assessed in ICU, in hospital, and at day 90. Among the 324 patients with septic shock, the death rate was 48%. The death rate reached 90% for the quantile of patients receiving more than 1 μg/kg per minute of norepinephrine. In our cohort, four independent factors associated with mortality were identified: age (odds ratio, 1.02 [95% confidence interval, 1.00-1.04]; P = 0.02), thrombocytopenia (odds ratio, 3.8 [95% confidence interval, 1.8-8.5]; P < 0.001), urine output less than 500 mL (odds ratio, 8.7 [95% confidence interval, 3.6-25]; P < 0.001), and dosage of norepinephrine greater than 1 μg/kg per minute (odds ratio, 9.7 [95% confidence interval, 4.5-23]; P < 0.001). However, because of the study's design, unmeasured confounding factors should be taken into account in our findings.
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http://dx.doi.org/10.1097/SHK.0000000000000426DOI Listing
October 2015

Impact of Extraperitoneal Dioxyde Carbon Insufflation on Respiratory Function in Anesthetized Adults: A Preliminary Study Using Electrical Impedance Tomography and Wash-out/Wash-in Technic.

Anesth Pain Med 2015 Feb 1;5(1):e22845. Epub 2015 Feb 1.

Department of Anesthesia and intensive care, Sainte Anne Military Teaching Hospital, Toulon, France.

Background: Extraperitoneal laparoscopy has become a common technique for many surgical procedures, especially for inguinal hernia surgery. Investigations of physiological changes occurring during extraperitoneal carbon dioxide (CO2) insufflation mostly focused on blood gas changes. To date, the impact of extraperitoneal CO2 insufflation on respiratory mechanics remains unknown, whereas changes in respiratory mechanics have been extensively studied in intraperitoneal insufflation.

Objectives: The aim of this study was to investigate the effects of extraperitoneal CO2 insufflation on respiratory mechanics.

Patients And Methods: A prospective and observational study was performed on nine patients undergoing laparoscopic inguinal hernia repair. Anesthetic management and intraoperative care were standardized. All patients were mechanically ventilated with a tidal volume of 8 mL/kg using an Engström Carestation ventilator (GE Healthcare). Ventilation distribution was assessed by electrical impedance tomography (EIT). End-expiratory lung volume (EELV) was measured by a nitrogen wash-out/wash-in method. Ventilation distribution, EELV, ventilator pressures and hemodynamic parameters were assessed before extraperitoneal insufflation, and during insufflation with a PEEP of 0 cmH2O, 5 cmH20 and of 10 cmH20.

Results: EELV and thoracopulmonary compliance were significantly decreased after extraperitoneal insufflation. Ventilation distribution was significantly higher in ventral lung regions during general anesthesia and was not modified after insufflation. A 10 cmH20 PEEP application resulted in a significant increase in EELV, and a shift of ventilation toward the dorsal lung regions.

Conclusions: Extraperitoneal insufflation decreased EELV and thoracopulmonary compliance. Application of a 10 cmH20 PEEP increased EELV and homogenized ventilation distribution. This preliminary clinical study showed that extraperitoneal insufflation worsened respiratory mechanics, which may justify further investigations to evaluate the clinical impact.
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http://dx.doi.org/10.5812/aapm.22845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350189PMC
February 2015

De-escalation versus continuation of empirical antimicrobial treatment in severe sepsis: a multicenter non-blinded randomized noninferiority trial.

Intensive Care Med 2014 Oct 5;40(10):1399-408. Epub 2014 Aug 5.

Service d'anesthésie et de réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France,

Background: In patients with severe sepsis, no randomized clinical trial has tested the concept of de-escalation of empirical antimicrobial therapy. This study aimed to compare the de-escalation strategy with the continuation of an appropriate empirical treatment in those patients.

Methods: This was a multicenter non-blinded randomized noninferiority trial of patients with severe sepsis who were randomly assigned to de-escalation or continuation of empirical antimicrobial treatment. Recruitment began in February 2012 and ended in April 2013 in nine intensive care units (ICUs) in France. Patients with severe sepsis were assigned to de-escalation (n = 59) or continuation of empirical antimicrobial treatment (n = 57). The primary outcome was to measure the duration of ICU stay. We defined a noninferiority margin of 2 days. If the lower boundary of the 95 % confidence interval (CI) for the difference in patients assigned to the de-escalation group was less than 2 days, as compared with that of patients assigned to the continuation group, de-escalation was considered to be noninferior to the continuation strategy. Secondary outcomes included mortality at 90 days, occurrence of organ failure, number of superinfections, and number of days with antibiotics during the ICU stay.

Results: The median duration of ICU stay was 9 [interquartile range (IQR) 5-22] days in the de-escalation group and 8 [IQR 4-15] days in the continuation group, respectively (P = 0.71). The mean difference was 3.4 (95 % CI -1.7 to 8.5). A superinfection occurred in 16 (27 %) patients in the de-escalation group and six (11 %) patients in the continuation group (P = 0.03). The numbers of antibiotic days were 9 [7-15] and 7.5 [6-13] in the de-escalation group and continuation group, respectively (P = 0.03). Mortality was similar in both groups.

Conclusion: As compared to the continuation of the empirical antimicrobial treatment, a strategy based on de-escalation of antibiotics resulted in prolonged duration of ICU stay. However, it did not affect the mortality rate.
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http://dx.doi.org/10.1007/s00134-014-3411-8DOI Listing
October 2014

Sleep disorders among French anaesthesiologists and intensivists working in public hospitals: a self-reported electronic survey.

Eur J Anaesthesiol 2015 Feb;32(2):132-7

From the Department of Anesthesiology and Intensive Care Medicine, Conception Hospital (ER, VB, LR, KH, CN, JA), the Department of Anesthesiology and Intensive Care Medicine, North Hospital (FA, ML) and the Department of Sleep Medicine, Timone Hospital (MR), Aix Marseille University, Marseille, France (AN).

Background: Sleep disorders can affect the health of physicians and patient outcomes.

Objectives: To determine the prevalence of sleep disorders among French anaesthesiologists and intensivists working in a public hospital.

Design: A cross-sectional survey.

Setting: Anaesthesiologists and intensivists working in French public hospitals.

Main Outcome Measures: Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS) was used to assess the degree of excessive daytime sleepiness.

Results: Among 1504 responders, 677 (45%) physicians reported sleep disorders. The independent factors associated with sleep disorders were reporting of sleep disorders [odds ratio (OR) 12.04, 95% CI (95% confidence interval) 8.89 to 16.46], sleep time less than 7 h (OR 8.86, 95% CI 6.50 to 12.20), work stress (OR 2.04, 95% CI 1.49 to 2.83), stress at home (OR 1.77, 95% CI 1.24 to 2.53), anxiolytic use (OR 3.69, 95% CI 2.23 to 6.25), psychotropic drug use (OR 3.91, 95% CI 1.51 to 11.52) and excessive daytime sleepiness (OR 1.81, 95% CI 1.34 to 2.45). Six hundred and seventy-six (44%) responders reported excessive daytime sleepiness during their professional activity. The independent factors associated with excessive daytime sleepiness were female sex (OR 1.86, 95% CI 1.49 to 2.34), tea consumption (OR 1.47, 95% CI 1.14 to 1.91), regular practice of nap (OR 1.68, 95% CI 1.34 to 2.09), stress at home (OR 1.31, 95% CI 1.02 to 1.68), more than four extended work shifts monthly (OR 1.25, 95% CI 1.01 to 1.56) and sleep disorders (OR 1.73, 95% CI 1.31 to 2.29). Reporting sleep disorder duration and a sleep time less than 7 h were the two major risk factors for sleep disorders. Female sex was the major risk factor for excessive daytime sleepiness.

Conclusion: French anaesthesiologists did not report more sleep disorders than the general population, but their alertness is impaired by a factor of two.
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February 2015

Lung ultrasound predicts interstitial syndrome and hemodynamic profile in parturients with severe preeclampsia.

Anesthesiology 2014 Apr;120(4):906-14

From the Department of Anesthesiology and Critical Care Medicine, North Hospital, Aix Marseille University, Marseille, France (L.Z., C.C., C.B., M.T., A.V., F.A., C.M., and M.L.); Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Nîmes University, Nîmes, France (L.M.); and North Hospital, Department of Obstetrics and Gynecology, Aix Marseille University, Marseille, France (F.B.).

Background: The role of lung ultrasound has never been evaluated in parturients with severe preeclampsia. The authors' first aim was to assess the ability of lung ultrasound to detect pulmonary edema in severe preeclampsia. The second aim was to highlight the relation between B-lines and increased left ventricular end-diastolic pressures.

Methods: This prospective cohort study was conducted in a level-3 maternity during a 12-month period. Twenty parturients with severe preeclampsia were consecutively enrolled. Both lung and cardiac ultrasound examinations were performed before (n = 20) and after delivery (n = 20). Each parturient with severe preeclampsia was compared with a control healthy parturient. Pulmonary edema was determined using two scores: the B-pattern and the Echo Comet Score. Left ventricular end-diastolic pressures were assessed by transthoracic echocardiography.

Results: Lung ultrasound detected interstitial edema in five parturients (25%) with severe preeclampsia. A B-pattern was associated to increased mitral valve early diastolic peak E (116 vs. 90 cm/s; P = 0.05) and to increased E/E' ratio (9.9 vs. 6.6; P < 0.001). An Echo Comet Score of greater than 25 predicted an increase in filling pressures (E/E' ratio >9.5) with a sensitivity and specificity of 1.00 (95% CI, 0.69 to 1.00) and 0.82 (95% CI, 0.66 to 0.92), respectively.

Conclusions: In parturients with severe preeclampsia, lung ultrasound detects both pulmonary edema and increased left ventricular end-diastolic pressures. The finding of a B-pattern should restrict the use of fluid. However, these preliminary results are associations from a single sample. They need to be replicated in a larger, definitive study.
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April 2014

Postoperative pain and subsequent PTSD-related symptoms in patients undergoing lung resection for suspected cancer.

J Thorac Oncol 2014 Mar;9(3):362-9

*Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France; †Service de Réanimation Médicale, Hôpital Saint-Louis, Université Diderot Paris 7, Paris, France; and ‡Service de Chirurgie Thoracique et Maladies de l'Œsophage, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France.

Background: Because lung cancer resection is at the crossroad between cancer and high-risk surgery, we hypothesized that the patients undergoing lung resection for cancer are exposed to develop a post-traumatic stress disorder (PTSD) syndrome-related symptoms.

Methods: Forty-seven adult patients were included in the study. Patients were eligible for inclusion if they underwent lung resection for suspected cancer, if they were able to speak and read French, and if they agreed to be reached for a telephone interview. We assessed before, immediately after, and 3 months after surgery the presence of symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) and PTSD-related symptoms (impact of events scale revised [IES-R]). At the 3-month assessment, an IES-R score > 22 was used as criteria for predicting the patients at risk of PTSD-related symptoms.

Results: We identified an IES-R score higher than 22 in 24 participants (51%). Patients with a preoperatory Hospital Anxiety and Depression Scale(anxiety) score more than 7 (T0) and a maximal visual analogic scale score more than 40 during the first 24 hours after surgery were more likely to develop PTSD-related symptoms at 3-months with odd ratios at 4.61 [1.20-17.73] (p = 0.03) and 1.34 [1.05-1.75] (p = 0.02).

Conclusion: The prevalence of PTSD-related symptoms after lung cancer resection is high, showing that lung cancer patients undergoing surgical resection are at high risk of postprocedure burden. The presence of preoperative symptoms of anxiety and acute procedural pain during the early postoperative period are strong predictors for developing PTSD-related symptoms after lung cancer surgery.
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March 2014

Routine use of Staphylococcus aureus rapid diagnostic test in patients with suspected ventilator-associated pneumonia.

Crit Care 2013 Aug 6;17(4):R170. Epub 2013 Aug 6.

Introduction: In patients with ventilator-associated pneumonia (VAP), administration of an appropriate empirical antimicrobial treatment is associated with improved outcomes, leading to the prescription of broad-spectrum antibiotics, including a drug active against methicillin resistant Staphylococcus aureus (MRSA). In order to avoid the overuse of antibiotics, the present study aimed to evaluate the technical characteristics of a rapid diagnostic test (Cepheid Xpert assay) in patients with suspected VAP.

Methods: From June 2011 to June 2012, in patients with suspected VAP, a sample from the bronchialalveolar lavage (BAL) or miniBAL was tested in a point-of-care laboratory for a rapid diagnostic test of methicillin susceptible Staphylococcus aureus (MSSA) and MRSA. Then, the result was compared to the quantitative culture with a threshold at 10⁴ colony-forming units per milliliter for bronchoalveolar lavage and 10³ colony-forming units per milliliter for minibronchoalveolar lavage. The study was performed in three intensive care units at two institutions.

Results: Four hundred, twenty-two samples from 328 patients were analyzed. The culture of 6 (1.1%) and 28 (6.5%) samples were positive for MRSA and MSSA. The test was not interpretable in 41 (9.3%) patients. The negative predictive values of the rapid detection test were 99.7% (98.1 to 99.9%) and 99.8% (98.7 to 99.9%) for MSSA and MRSA, respectively.

Conclusion: The rapid diagnostic test is reliable in excluding the presence of MSSA and MRSA in the samples of patients with suspected VAP. Its utility should be regarded depending on the prevalence of MRSA.
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http://dx.doi.org/10.1186/cc12849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056790PMC
August 2013

Lidocaine versus ropivacaine for perineal infiltration post-episiotomy.

Int J Gynaecol Obstet 2013 Jul 8;122(1):33-6. Epub 2013 Apr 8.

Department of Anesthesia and Reanimation, APHM Hôpital Nord, Marseille, France.

Objective: To evaluate maternal analgesia after an episiotomy during delivery.

Methods: The present case-control study compared 2 protocols of post-episiotomy infiltration: period A, 20 mL of lidocaine 10mg/mL; period B, 20 mL of ropivacaine 7.5mg/mL. The primary study endpoint was the visual analog scale (VAS) score at 24 hours after episiotomy; secondary endpoints were the VAS scores during suturing and at 2 and 48 hours, and patient satisfaction at 48 hours.

Results: In total, 102 women were included in the study. The median VAS score at 24 hours was significantly lower during the ropivacaine period (3 [1.5-4]) than during the lidocaine period (4 [2-6]; P=0.004). A VAS score below 4 at 24 hours was significantly more frequent with ropivacaine (71% versus 43%; P=0.009). The VAS scores at 2 and 48 hours were also lower in the ropivacaine group (2 hours, 0 [0-1] versus 1 [0-3], P=0.01; and 48 hours, 2 [0-3] versus 3 [2-5], P<0.001). Maternal satisfaction was significantly higher in the ropivacaine group.

Conclusion: Analgesia and maternal satisfaction were improved during the period when ropivacaine was used as opposed to lidocaine. The effect lasted for up to 48 hours.
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http://dx.doi.org/10.1016/j.ijgo.2013.01.028DOI Listing
July 2013

Prediction of fluid responsiveness in severe preeclamptic patients with oliguria.

Intensive Care Med 2013 Apr 6;39(4):593-600. Epub 2012 Dec 6.

Service d'anesthésie et de réanimation, Hôpital Nord, Aix Marseille University, 13915, Marseille cedex 20, France.

Purpose: Because severe preeclampsia (SP) may be associated with acute pulmonary oedema, fluid responsiveness needs to be accurately predicted. Passive leg raising (PLR) predicts fluid responsiveness. PLR has never been reported during pregnancy. Our first aim was to determine the percentage of SP patients with oliguria increasing their stroke volume after fluid challenge. Our second aim was to assess the accuracy of PLR to predict fluid responsiveness in those patients.

Methods: Patients with SP were prospectively included in the study. In the subgroup developing oliguria, transthoracic echocardiography was performed at baseline, during PLR and after a 500 ml fluid infusion over 15 min. Fluid responders were defined by a 15 % increase of stroke volume index. Five consecutive measurements were averaged for all parameters.

Results: Twenty-three (56 %) out of 41 patients with SP developed oliguria, 12 (52 %) out of these 23 responded to fluid challenge. During PLR, an increase of the velocity time integral of subaortic blood flow (ΔVTI) above 12 % predicted the response with a sensitivity and specificity of 75 [95 % confident interval (CI): 0.42-0.95] and 100 % (95 % CI: 0.72-1.00), respectively. An algorithm combining ΔVTI and the baseline value of VTI predicted fluid responsiveness with a sensitivity and specificity of 100 % (95 % CI: 0.74-1.00) and (95 % CI: 0.75-1.00). Urine output and respiratory variations of inferior vena cava diameter did not predict fluid responsiveness.

Conclusions: Only 52 % of oliguric patients were responders. PLR accurately predicts fluid responsiveness in the specific setting of SP. This noninvasive test should be tested in future algorithms for the management of SP.
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http://dx.doi.org/10.1007/s00134-012-2770-2DOI Listing
April 2013

Is surgical excision of lipomas arising from the parotid gland systematically required?

Eur Arch Otorhinolaryngol 2012 Jul 25;269(7):1839-44. Epub 2011 Nov 25.

Service ORL et Chirurgie Cervico-Faciale, Pôle Cervico-Facial, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire, La Timone, 264, rue Saint Pierre, 13385 Marseille cedex 05, France.

Lipomas arising from the parotid gland are very rare. We report a 10-year experience in a single institution (La Timone University Hospital of Marseille, France). Among 614 parotidectomies for neoplasms performed from 1998 to 2008, 12 lipomas were identified. A retrospective analysis based on medical records was made. Evaluation, analysis and current management of lipomas of the parotid gland are described. Lipomas accounted for 2% of all parotid neoplasms and 2.6% of benign tumors in our series. The median age of patients was 60 years with a M/F sex ratio of 5-1. The main presentation was a soft asymptomatic, slow-growing, mobile mass although 30% had an indurated mass on palpation. Diagnosis of lipoma, based on the results of imaging, was made preoperatively in all cases. The mean tumor duration prior to excision was 11.5 months. The surgical decision was made regarding increased swelling with functional/esthetic discomfort in 83% of cases. Partial parotidectomy was performed in most cases. Postoperative complications occurred in 16% of cases although no permanent complication was observed. No recurrence was observed in our series. Histologically, 92% of tumors were classic lipomas. Lipomas can be clinically misleading since 30% of patients in our series showed an indurated mass on palpation. Preoperative imaging, especially MRI, is the cornerstone of their management as it allows very accurate lipoma diagnosis. Since in our series, diagnosis of lipoma had been made preoperatively in all cases, the surgical excision could be delayed and finally surgical decision has been made for esthetic and/or functional considerations in more than 80% of cases.
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July 2012

High central venous oxygen saturation in the latter stages of septic shock is associated with increased mortality.

Crit Care 2011 Jul 26;15(4):R176. Epub 2011 Jul 26.

Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, Université de la Méditerranée, Chemin des bourrely, 13915 Marseille Cedex 20, France.

Introduction: Current guidelines recommend maintaining central venous oxygen saturation (ScvO2) higher than 70% in patients with severe sepsis and septic shock. As high levels of ScvO2 may reflect an inadequate use of oxygen, our aim was to evaluate the relation between maximal ScvO2 levels (ScvO2max) and survival among intensive care unit (ICU) patients with septic shock.

Methods: We retrospectively analyzed data from all admissions to our ICU between January 2008 and December 2009. All septic shock patients in whom the ScvO2 was measured were included. The measures of ScvO2max within the first 72 hours after the onset of shock were collected.

Results: A total of 1,976 patients were screened and 152 (7.7%) patients met the inclusion criteria. The level of ScvO2max was 85% (78 to 89) in the non-survivors, compared with 79% (72 to 87) in the survivors (P = 0.009).

Conclusions: Our findings raise concerns about high levels of ScvO2 in patients with septic shock. This may reflect the severity of the shock with an impaired oxygen use. Future strategies may target an optimization of tissue perfusion in this specific subgroup of patients.
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http://dx.doi.org/10.1186/cc10325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387619PMC
July 2011

Monitoring of plasma creatinine and urinary γ-glutamyl transpeptidase improves detection of acute kidney injury by more than 20%.

Crit Care Med 2011 Jan;39(1):52-6

Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France.

Objectives: We sought to determine how early we can detect acute kidney injury inpatients at intensive care unit admission by combining the use of plasma creatinine and urinary γ-glutamyl transpeptidase.

Design: Prospective study including development (n = 100) and validation (n = 56) cohorts.

Settings: Intensive care unit of a university hospital.

Interventions: None.

Measurements And Main Results: To determine acute kidney injury, we subtracted measured creatinine clearance from theoretical creatinine clearance with a 25% reduction signifying acute kidney injury. Its incidence in 100 consecutive patients was 36%. An indexed urinary γ-glutamyl transpeptidase-to-urinary creatinine ratio was significantly increased in the patients with acute kidney injury and did not correlate with plasma creatinine (p = .3). Using a predefined threshold of indexed urinary γ-glutamyl transpeptidase-to-urinary creatinine ratio (>12.4 units/mmol) and plasma creatinine (>89 μmol/L), acute kidney injury detection was significantly improved, making it possible to detect 22 (22%) additional patients with acute kidney injury. This finding was confirmed in the validation group. The rates of false-positive results were 30% and 19% in the data development and internal validation cohorts, respectively.

Conclusions: The use of low-cost, widely available markers (creatinine and urinary γ-glutamyl transpeptidase) increases the detection of acute kidney injury. Further studies are needed to determine the impact on outcome with the use of these biomarkers.
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January 2011

Non-adherence to guidelines: an avoidable cause of failure of empirical antimicrobial therapy in the presence of difficult-to-treat bacteria.

Intensive Care Med 2010 Jan 24;36(1):75-82. Epub 2009 Sep 24.

Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Chemin des Bourrely, 13915 Marseille Cedex 20, France.

Purpose: To identify the risk factors of ventilator-associated pneumonia (VAP) due to difficult-to-treat (DTT) bacteria (i.e., Pseudomonas aeruginosa, Acinetobacter baumannii and oxacillin-resistant Staphylococcus aureus), and to assess the rate and the causes of inappropriateness of empirical antimicrobial therapy.

Methods: In an intensive care unit of a university hospital, patients with VAP were empirically treated with antibiotics without activity against DTT bacteria if the patients had no prior hospitalization or prior administration of antibiotics, according to local guidelines.

Results: Overall, the empirical antimicrobial therapy was appropriate in 190 (87%) out of 218 patients with VAP. Fifty (23%) patients developed problems due to DTT bacteria. The risk factors for VAP due to DTT bacteria were shock state, prior antimicrobial therapy, prior stay in long-term care facilities and late-onset VAP. Empirical antimicrobial therapy was inappropriate in 20 (40%) patients with VAP due to DTT bacteria and 8 (5%) patients with VAP due to non-DTT (P = 0.001). Guidelines violations (nine patients), bacteria not included in antibiotic spectrum (eight patients) and bacterial resistance (three patients) were the causes of inappropriateness in case of DTT bacteria.

Conclusion: Despite the abundant information for the treatment of VAP and the establishment of guidelines, too many patients with DTT bacteria received inappropriate antimicrobial therapy. Since 45% of the cases are related to non-adherence to the local protocol, there is room for improvement by implementing educational programs. Also, since DTT bacteria are found in 23% of late-onset VAP, empirical antibiotic treatment should be directed against these pathogens.
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http://dx.doi.org/10.1007/s00134-009-1660-8DOI Listing
January 2010

Oxygen tissue saturation is lower in nonsurvivors than in survivors after early resuscitation of septic shock.

Anesthesiology 2009 Aug;111(2):366-71

Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille and Université de la Méditerranée, Marseille, France.

Background: Growing evidence suggests that the microvascular dysfunction is the key element of the pathogenesis of septic shock. This study's purpose was to explore whether the outcome of septic shock patients after early resuscitation using early goal-directed therapy is related to their muscle tissue oxygenation.

Methods: Tissue oxygen saturation (Sto2) was monitored in septic shock patients using a tissue spectrometer (InSpectra Model 325; Hutchinson Technology, Hutchinson, MN). For the purpose of this retrospective study, the Sto2 values were collected at the first measurement done after the macrohemodynamic variables (mean arterial pressure, urine output, central venous saturation in oxygen) were optimized.

Results: After the hemodynamic variables were corrected, no difference was observed between the nonsurvivors and survivors, with the exception of pulse oximetry saturation (94% [92-97%] vs. 97% [94-99%], P = 0.04). The Sto2 values were significantly lower in the nonsurvivors than in the survivors (73% [68-82%] vs. 84% [81-90%], P = 0.02). No correlations were found between the Sto2 and Spo2 (P = 0.7).

Conclusions: In septic shock patients, tissue oxygen saturation below 78% is associated with increased mortality at day 28. Further investigations are required to determine whether the correction of an impaired level of tissue oxygen saturation may improve the outcome of these patients.
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August 2009
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