Publications by authors named "Guillaume Louis"

43 Publications

The AKIKI 2 trial: a case for strategy of initiation instead of timing - Authors' reply.

Lancet 2021 Oct;398(10307):1215-1216

Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPIRIT, Médecine Intensive-Réanimation, Colombes 92110, France. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(21)01954-1DOI Listing
October 2021

The white test for intraoperative screening of bile leakage: a potential trigger factor for acute pancreatitis after liver resection-a case series.

BMC Surg 2021 Oct 2;21(1):356. Epub 2021 Oct 2.

Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 264 rue Saint-Pierre, 13385, Marseille Cedex 05, France.

Background: Acute pancreatitis after liver resection is a rare but serious complication, and few cases have been described in the literature. Extended lymphadenectomy, and long ischemia due to the Pringle maneuver could be responsible of post-liver resection acute pancreatitis, but the exact causes of AP after hepatectomy remain unclear.

Cases Presentation: We report here three cases of AP after hepatectomy and we strongly hypothesize that this is due to the bile leakage white test. 502 hepatectomy were performed at our center and 3 patients (0.6%) experienced acute pancreatitis after LR and all of these three patients underwent the white test at the end of the liver resection. None underwent additionally lymphadenectomy to the liver resection. All patient had a white-test during the liver surgery. We identified distal implantation of the cystic duct in these three patients as a potential cause for acute pancreatitis.

Conclusion: The white test is useful for detection of bile leakage after liver resection, but we do not recommend a systematic use after LR, because severe acute pancreatitis can be lethal for the patient, especially in case of distal cystic implantation which may facilitate reflux in the main pancreatic duct.
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http://dx.doi.org/10.1186/s12893-021-01354-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8487543PMC
October 2021

Infection related catheter complications in patients undergoing prone positioning for acute respiratory distress syndrome: an exposed/unexposed study.

BMC Infect Dis 2021 Jun 7;21(1):534. Epub 2021 Jun 7.

Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée de Château, 57085, Metz, France.

Background: Prone positioning (PP) is a standard of care for patients with moderate-severe acute respiratory distress syndrome (ARDS). While adverse events associated with PP are well-documented in the literature, research examining the effect of PP on the risk of infectious complications of intravascular catheters is lacking.

Method: All consecutive ARDS patients treated with PP were recruited retrospectively over a two-year period and formed the exposed group. Intensive care unit (ICU) patients during the same period without ARDS for whom PP was not conducted but who had an equivalent disease severity were matched 1:1 to the exposed group based on age, sex, centre, length of ICU stay and SAPS II (unexposed group). Infection-related catheter complications were defined by a composite criterion, including catheter tip colonization or intravascular catheter-related infection.

Results: A total of 101 exposed patients were included in the study. Most had direct ARDS (pneumonia). The median [Q1-Q3] PP session number was 2 [1-4]. These patients were matched with 101 unexposed patients. The mortality rates of the exposed and unexposed groups were 31 and 30%, respectively. The incidence of the composite criterion was 14.2/1000 in the exposed group compared with 8.2/1000 days in the control group (p = 0.09). Multivariate analysis identified PP as a factor related to catheter colonization or infection (p = 0.04).

Conclusion: Our data suggest that PP is associated with a higher risk of CVC infectious complications.
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http://dx.doi.org/10.1186/s12879-021-06197-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182343PMC
June 2021

Mental health and stress among ICU healthcare professionals in France according to intensity of the COVID-19 epidemic.

Ann Intensive Care 2021 Jun 4;11(1):90. Epub 2021 Jun 4.

Service de Médecine Intensive Réanimation-Unité de Sevrage Ventilatoire et Réhabilitation, CH de Bethune, Bethune, France.

Background: We investigated the impact of the COVID-19 crisis on mental health of professionals working in the intensive care unit (ICU) according to the intensity of the epidemic in France.

Methods: This cross-sectional survey was conducted in 77 French hospitals from April 22 to May 13 2020. All ICU frontline healthcare workers were eligible. The primary endpoint was the mental health, assessed using the 12-item General Health Questionnaire. Sources of stress during the crisis were assessed using the Perceived Stressors in Intensive Care Units (PS-ICU) scale. Epidemic intensity was defined as high or low for each region based on publicly available data from Santé Publique France. Effects were assessed using linear mixed models, moderation and mediation analyses.

Results: In total, 2643 health professionals participated; 64.36% in high-intensity zones. Professionals in areas with greater epidemic intensity were at higher risk of mental health issues (p < 0.001), and higher levels of overall perceived stress (p < 0.001), compared to low-intensity zones. Factors associated with higher overall perceived stress were female sex (B = 0.13; 95% confidence interval [CI] = 0.08-0.17), having a relative at risk of COVID-19 (B = 0.14; 95%-CI = 0.09-0.18) and working in high-intensity zones (B = 0.11; 95%-CI = 0.02-0.20). Perceived stress mediated the impact of the crisis context on mental health (B = 0.23, 95%-CI = 0.05, 0.41) and the impact of stress on mental health was moderated by positive thinking, b = - 0.32, 95% CI = - 0.54, - 0.11.

Conclusion: COVID-19 negatively impacted the mental health of ICU professionals. Professionals working in zones where the epidemic was of high intensity were significantly more affected, with higher levels of perceived stress. This study is supported by a grant from the French Ministry of Health (PHRC-COVID 2020).
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http://dx.doi.org/10.1186/s13613-021-00880-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177250PMC
June 2021

Preliminary data on severe SARS-CoV-2 infection caused by the 501Y.V2 variant.

Anaesth Crit Care Pain Med 2021 08 24;40(4):100890. Epub 2021 May 24.

Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée du château, 57085 Metz, France.

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http://dx.doi.org/10.1016/j.accpm.2021.100890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141690PMC
August 2021

Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial.

Lancet 2021 04;397(10281):1293-1300

Réanimation médicale, CHRU de Lille, Hôpital Roger Salengro, Lille, France.

Background: Delaying renal replacement therapy (RRT) for some time in critically ill patients with severe acute kidney injury and no severe complication is safe and allows optimisation of the use of medical devices. Major uncertainty remains concerning the duration for which RRT can be postponed without risk. Our aim was to test the hypothesis that a more-delayed initiation strategy would result in more RRT-free days, compared with a delayed strategy.

Methods: This was an unmasked, multicentre, prospective, open-label, randomised, controlled trial done in 39 intensive care units in France. We monitored critically ill patients with severe acute kidney injury (defined as Kidney Disease: Improving Global Outcomes stage 3) until they had oliguria for more than 72 h or a blood urea nitrogen concentration higher than 112 mg/dL. Patients were then randomly assigned (1:1) to either a strategy (delayed strategy) in which RRT was started just after randomisation or to a more-delayed strategy. With the more-delayed strategy, RRT initiation was postponed until mandatory indication (noticeable hyperkalaemia or metabolic acidosis or pulmonary oedema) or until blood urea nitrogen concentration reached 140 mg/dL. The primary outcome was the number of days alive and free of RRT between randomisation and day 28 and was done in the intention-to-treat population. The study is registered with ClinicalTrial.gov, NCT03396757 and is completed.

Findings: Between May 7, 2018, and Oct 11, 2019, of 5336 patients assessed, 278 patients underwent randomisation; 137 were assigned to the delayed strategy and 141 to the more-delayed strategy. The number of complications potentially related to acute kidney injury or to RRT were similar between groups. The median number of RRT-free days was 12 days (IQR 0-25) in the delayed strategy and 10 days (IQR 0-24) in the more-delayed strategy (p=0·93). In a multivariable analysis, the hazard ratio for death at 60 days was 1·65 (95% CI 1·09-2·50, p=0·018) with the more-delayed versus the delayed strategy. The number of complications potentially related to acute kidney injury or renal replacement therapy did not differ between groups.

Interpretation: In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm.

Funding: Programme Hospitalier de Recherche Clinique.
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http://dx.doi.org/10.1016/S0140-6736(21)00350-0DOI Listing
April 2021

Performance of the ROX index to predict intubation in immunocompromised patients receiving high-flow nasal cannula for acute respiratory failure.

Ann Intensive Care 2021 Jan 27;11(1):17. Epub 2021 Jan 27.

Service de Médecine Interne, Soins Intensifs & Urgences Oncologiques, Institut Jules Bordet, Bruxelles, Université Libre de Bruxelles (ULB), Brussels, Belgium.

Background: Delayed intubation is associated with high mortality. There is a lack of objective criteria to decide the time of intubation. We assessed a recently described combined oxygenation index (ROX index) to predict intubation in immunocompromised patients. The study is a secondary analysis of randomized trials in immunocompromised patients, including all patients who received high-flow nasal cannula (HFNC). The first objective was to evaluate the accuracy of the ROX index to predict intubation for patients with acute respiratory failure.

Results: In the study, 302 patients received HFNC. Acute respiratory failure was mostly related to pneumonia (n = 150, 49.7%). Within 2 (1-3) days, 115 (38.1%) patients were intubated. The ICU mortality rate was 27.4% (n = 83). At 6 h, the ROX index was lower for patients who needed intubation compared with those who did not [4.79 (3.69-7.01) vs. 6.10 (4.48-8.68), p < 0.001]. The accuracy of the ROX index to predict intubation was poor [AUC = 0.623 (0.557-0.689)], with low performance using the threshold previously found (4.88). In multivariate analysis, a higher ROX index was still independently associated with a lower intubation rate (OR = 0.89 [0.82-0.96], p = 0.04).

Conclusion: A ROX index greater than 4.88 appears to have a poor ability to predict intubation in immunocompromised patients with acute respiratory failure, although it remains highly associated with the risk of intubation and may be useful to stratify such risk in future studies.
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http://dx.doi.org/10.1186/s13613-021-00801-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838224PMC
January 2021

SARS-Cov-2 fulminant myocarditis: an autopsy and histopathological case study.

Int J Legal Med 2021 Mar 3;135(2):577-581. Epub 2021 Jan 3.

Department of Intensive Care Medicine, CHR Metz-Thionville, Ars-Laquenexy, France.

The coronavirus disease 2019 (COVID-19), due to SARS-CoV-2, is primarily a respiratory disease, causing in most severe cases life-threatening acute respiratory distress syndrome (ARDS). Cardiovascular involvement can also occur, such as thrombosis or myocarditis, generally associated with pulmonary lesions. Little is known about SARS-CoV-2-induced myocarditis. We report the case of a 69-year-old man suffering from a refractory cardiogenic shock, without significant lung involvement. Prior to death, several nasopharyngeal swabs and distal bronchoalveolar lavage were sampled in order to perform RT-PCR analyses for SARS-CoV-2-RNA, which all gave negative results. Autopsy showed coronary atherosclerosis, without acute complication. Microscopic examination of the heart revealed the existence of an intense multifocal inflammatory infiltration, in both ventricles and septum, composed in its majority of macrophages and CD8+ cytotoxic T lymphocytes (CD4/CD8 ratio: 0.11). Immunohistochemistry for anti-SARS nucleocapsid protein antibody was strongly positive in myocardial cells, but not in lung tissue. RT-PCR was realized on formalin-fixed paraffin-embedded lung and heart tissue blocks: only heart tissue was positive for SARS-CoV-2 RNA. In conclusion, this exhaustive post-mortem pathological case study of fulminant myocarditis demonstrates the presence of SARS-CoV-2 RNA in heart tissue, without significant lung involvement. Immunohistochemistry showed that the virus was specifically localized in cardiomyocytes and induced a strong cytotoxic T cells inflammatory response. This case report thus gives new insight in the pathogenesis of SARS-CoV-2-induced myocarditis and emphasizes on the importance and reliability of post-mortem analyses in order to better understand the physiopathology of this worldwide spreading new viral disease.
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http://dx.doi.org/10.1007/s00414-020-02500-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7779100PMC
March 2021

Acute kidney injury in severe SARS-CoV-2 infection: An experience report in Eastern France.

Anaesth Crit Care Pain Med 2021 02 29;40(1):100788. Epub 2020 Nov 29.

Plateforme d'Appui à la Recherche Clinique, CHR Metz-Thionville Hôpital de Mercy, 57085 Metz, France.

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http://dx.doi.org/10.1016/j.accpm.2020.100788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700728PMC
February 2021

Epidemiology and outcome of patients admitted to intensive care after anaphylaxis in France: a retrospective multicentre study.

Br J Anaesth 2020 12 12;125(6):1025-1033. Epub 2020 Sep 12.

Service d'Anesthésie-Réanimation Chirurgicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.

Background: Few data are available on patients who have experienced anaphylaxis and were admitted to ICUs. The purpose of this observational study was to describe the epidemiology and management of these patients.

Methods: This was a multicentre retrospective study carried out in 23 French ICUs between 2012 and 2017. All patients who suffered anaphylaxis and were transferred to an ICU were included. Data were collected using an electronic database after approval by an ethics committee.

Results: A total of 339 patients were included, and 17 (5%) died secondary to anaphylaxis. The main triggers were drugs (77%), contrast media (11%), and food (7%). Epinephrine was administered before ICU admission in 88% of patients with Grade III anaphylaxis and 100% of patients with Grade IV anaphylaxis. Most patients with Grades III and IV anaphylaxes did not receive the recommended dose of i.v. fluid of 30 ml kg within the first 4 h of ICU admission. The time to epinephrine administration was not statistically different between survivors and non-survivors, but non-survivors received a higher dose of epinephrine (median: 5 [3-10] vs 3 [2-7] mg; P<0.0001), which suggests that some forms of anaphylactic shock may be resistant to epinephrine. In multivariate analysis, only lactate concentration at ICU admission was a predictor of death (odds ratio: 1.47 [1.15-1.88]; P=0.002).

Conclusions: Lactate concentration at ICU admission appeared to be the most reliable criterion for assessing prognosis. Epinephrine is widely used during anaphylaxis, but the volume of fluid resuscitation was consistently lower than recommended.

Clinical Trial Registration: NCT04290507.
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http://dx.doi.org/10.1016/j.bja.2020.08.024DOI Listing
December 2020

Prognostic factors associated with six month mortality of critically ill elderly patients admitted to the intensive care unit with severe acute cholangitis.

HPB (Oxford) 2021 Mar 22;23(3):459-467. Epub 2020 Aug 22.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandœuvre-Lès-Nancy F-54511, France; University of Lorraine, F-54000 Nancy, France.

Background: Little is known about the outcomes of elderly patients admitted to the intensive care unit (ICU) with severe acute cholangitis (SAC). The objectives were to describe the 6-month mortality in patients with SAC ≥75 years and to identify factors associated with this mortality.

Methods: Bi-center retrospective study of critically ill elderly patients with SAC conducted between 2013 and 2017. Demographic and clinical variables of ICU and hospital stays with a 6-month follow-up were analyzed.

Results: 85 patients, with a median [Q1-Q3] age of 83 [80-89] years were enrolled of whom 51 (60%) were men. SAC was due to choledocholithiasis in 72 (85%) patients. Median [Q1-Q3] ICU length of stay was 3 [2-6] days. Median [Q1-Q3] admission SAPS II was 50 [42-70]. The ICU and 6-month mortality rates were 18% and 48% respectively. Multivariate analysis showed that malnutrition (OR = 34.5, 95% CI [1.4-817.9]) and a decrease in SOFA score at 48 h (OR by unit 0.7, 95% CI [0.5-0.9]) were associated with higher 6-month mortality.

Conclusion: In their decision-making process, ICU physicians and hepato-pancreato-biliary surgeons could use these data to estimate the probability of survival of an elderly patient presenting with SAC and to offer time-limited trials of intensive care.

Trial Registration: NCT03831529.
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http://dx.doi.org/10.1016/j.hpb.2020.08.003DOI Listing
March 2021

Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome.

N Engl J Med 2020 03;382(11):999-1008

From the Medical Intensive Care Unit (L.B., H.W., L.V., G.C.), the Anesthesia and Intensive Care Unit (L.B., S.P.-F.), Unité de Méthodologie, INSERM Clinical Investigation Center 1431, University Hospital (F. Mauny, M.P.), and Research Unit EA3920, Université de Franche Comté (L.B., H.W. S.P.-F., G.C.), Besançon, the Medical Intensive Care Unit, University Hospital of Angers, Angers (P.A.), the Intensive Care Unit, General Hospital of Avignon, Avignon (F. Montini), the Intensive Care Unit, General Hospital of Nord Franche-Comté, Trévenans (J.B.), the Medical Intensive Care Unit (J.-P.Q.) and the Anesthesia and Intensive Care Unit (B.B.), University Hospital of Dijon, Dijon, the Intensive Care Unit, General Hospital of Metz-Thionville, Metz (G.L.), the Medical Intensive Care Unit (B.S.) and the Anesthesia and Intensive Care Unit (J.-M.C.), University Hospital of Clermont-Ferrand, Clermont-Ferrand, the Anesthesia and Intensive Care Unit, University Hospital of Strasbourg, Strasbourg (O.C., J.P.), and the Medical Intensive Care Unit, University Hospital of Nancy, Nancy (B.L.) - all in France; and the Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia (G.C.).

Background: In patients with acute respiratory distress syndrome (ARDS), the National Heart, Lung, and Blood Institute ARDS Clinical Trials Network recommends a target partial pressure of arterial oxygen (Pao) between 55 and 80 mm Hg. Prospective validation of this range in patients with ARDS is lacking. We hypothesized that targeting the lower limit of this range would improve outcomes in patients with ARDS.

Methods: In this multicenter, randomized trial, we assigned patients with ARDS to receive either conservative oxygen therapy (target Pao, 55 to 70 mm Hg; oxygen saturation as measured by pulse oximetry [Spo], 88 to 92%) or liberal oxygen therapy (target Pao, 90 to 105 mm Hg; Spo, ≥96%) for 7 days. The same mechanical-ventilation strategies were used in both groups. The primary outcome was death from any cause at 28 days.

Results: After the enrollment of 205 patients, the trial was prematurely stopped by the data and safety monitoring board because of safety concerns and a low likelihood of a significant difference between the two groups in the primary outcome. Four patients who did not meet the eligibility criteria were excluded. At day 28, a total of 34 of 99 patients (34.3%) in the conservative-oxygen group and 27 of 102 patients (26.5%) in the liberal-oxygen group had died (difference, 7.8 percentage points; 95% confidence interval [CI], -4.8 to 20.6). At day 90, 44.4% of the patients in the conservative-oxygen group and 30.4% of the patients in the liberal-oxygen group had died (difference, 14.0 percentage points; 95% CI, 0.7 to 27.2). Five mesenteric ischemic events occurred in the conservative-oxygen group.

Conclusions: Among patients with ARDS, early exposure to a conservative-oxygenation strategy with a Pao between 55 and 70 mm Hg did not increase survival at 28 days. (Funded by the French Ministry of Health; LOCO ClinicalTrials.gov number, NCT02713451.).
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http://dx.doi.org/10.1056/NEJMoa1916431DOI Listing
March 2020

Influence of deprivation on initial severity and prognosis of patients admitted to the ICU: the prospective, multicentre, observational IVOIRE cohort study.

Ann Intensive Care 2020 Feb 11;10(1):20. Epub 2020 Feb 11.

INSERM, CIC 1432, Module Epidémiologie Clinique, Dijon, France.

Background: The influence of socioeconomic status on patient outcomes is unclear. We assessed the impact of socioeconomic deprivation on severity of illness at intensive care unit (ICU) admission, and on the risk of death at 3 months after ICU admission.

Methods: The IVOIRE study was a prospective, observational, multicentre cohort study in the ICU of 8 participating hospitals in France, including patients aged ≥ 18 years admitted to the ICU and receiving at least one life support therapy for organ failure. The primary outcomes were severity at admission (assessed by SAPSII score), and mortality at 3 months. Socioeconomic data were obtained from interviews with patients or family. Deprivation was assessed using the EPICES score.

Results: Among 1294 patents included between 2013 and 2016, 629 (48.6%) were classed as deprived and differed significantly from non-deprived subjects in terms of sociodemographic characteristics and pre-existing conditions. The mean SAPS II score at admission was 50.1 ± 19.4 in deprived patients and 52.3 ± 17.3 in non-deprived patients, with no significant difference by multivariable analysis (β = - 1.85 [95% CI - 3.86; + 0.16, p = 0.072]). The proportion of death was 31.1% at 3 months, without significant differences between deprived and non-deprived patients, even after adjustment for confounders.

Conclusions: Deprivation is frequent in patients admitted to the ICU and is not associated with disease severity at admission, or with mortality at 3 months between deprived and non-deprived patients. Trial registration The IVOIRE cohort is registered with ClinicalTrials.gov under the identifier NCT01907581, registration date 17/7/2013.
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http://dx.doi.org/10.1186/s13613-020-0637-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7013026PMC
February 2020

The Artificial Kidney Initiation in Kidney Injury 2 (AKIKI2): study protocol for a randomized controlled trial.

Trials 2019 Dec 16;20(1):726. Epub 2019 Dec 16.

Réanimation médicale, CHRU de Lille, Hôpital Roger Salengro, 59037, Lille, France.

Background: The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial showed that a delayed renal replacement therapy (RRT) strategy for severe acute kidney injury (AKI) in critically ill patients was safe and associated with major reduction in RRT initiation compared with an early strategy. The five criteria which mandated RRT initiation in the delayed arm were: severe hyperkalemia, severe acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia, serum urea concentration > 40 mmol/l and oliguria/anuria > 72 h. However, duration of anuria/oliguria and level of blood urea are still criteria open to debate. The objective of the study is to compare the delayed strategy used in AKIKI (now termed "standard") with another in which RRT is further delayed for a longer period (termed "delayed strategy").

Methods/design: This is a prospective, multicenter, open-label, two-arm randomized trial. The study is composed of two stages (observational and randomization stages). At any time, the occurrence of a potentially severe condition (severe hyperkalemia, severe metabolic or mixed acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia) suggests immediate RRT initiation. Patients receiving (or who have received) intravenously administered catecholamines and/or invasive mechanical ventilation and presenting with AKI stage 3 of the KDIGO classification and with no potentially severe condition are included in the observational stage. Patients presenting a serum urea concentration > 40 mmol/l and/or an oliguria/anuria for more than 72 h are randomly allocated to a standard (RRT is initiated within 12 h) or a delayed RRT strategy (RRT is initiated only if an above-mentioned potentially severe condition occurs or if the serum urea concentration reaches 50 mmol/l). The primary outcome will be the number of RRT-free days at day 28. One interim analysis is planned. It is expected to include 810 patients in the observational stage and to randomize 270 subjects.

Discussion: The AKIKI2 study should improve the knowledge of RRT initiation criteria in critically ill patients. The potential reduction in RRT use allowed by a delayed RRT strategy might be associated with less invasive care and decreased costs. Enrollment is ongoing. Inclusions are expected to be completed by November 2019.

Trial Registration: ClinicalTrials.gov, ID: NCT03396757. Registered on 11 January 2018.
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http://dx.doi.org/10.1186/s13063-019-3774-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6915917PMC
December 2019

Outcomes of Stenotrophomonas maltophilia hospital-acquired pneumonia in intensive care unit: a nationwide retrospective study.

Crit Care 2019 11 21;23(1):371. Epub 2019 Nov 21.

Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.

Background: There is little descriptive data on Stenotrophomonas maltophilia hospital-acquired pneumonia (HAP) in critically ill patients. The optimal modalities of antimicrobial therapy remain to be determined. Our objective was to describe the epidemiology and prognostic factors associated with S. maltophilia pneumonia, focusing on antimicrobial therapy.

Methods: This nationwide retrospective study included all patients admitted to 25 French mixed intensive care units between 2012 and 2017 with hospital-acquired S. maltophilia HAP during intensive care unit stay. Primary endpoint was time to in-hospital death. Secondary endpoints included microbiologic effectiveness and antimicrobial therapeutic modalities such as delay to appropriate antimicrobial treatment, mono versus combination therapy, and duration of antimicrobial therapy.

Results: Of the 282 patients included, 84% were intubated at S. maltophilia HAP diagnosis for duration of 11 [5-18] days. The Simplified Acute Physiology Score II was 47 [36-63], and the in-hospital mortality was 49.7%. Underlying chronic pulmonary comorbidities were present in 14.1% of cases. Empirical antimicrobial therapy was considered effective on S. maltophilia according to susceptibility patterns in only 30% of cases. Delay to appropriate antimicrobial treatment had, however, no significant impact on the primary endpoint. Survival analysis did not show any benefit from combination antimicrobial therapy (HR = 1.27, 95%CI [0.88; 1.83], p = 0.20) or prolonged antimicrobial therapy for more than 7 days (HR = 1.06, 95%CI [0.6; 1.86], p = 0.84). No differences were noted in in-hospital death irrespective of an appropriate and timely empiric antimicrobial therapy between mono- versus polymicrobial S. maltophilia HAP (p = 0.273). The duration of ventilation prior to S. maltophilia HAP diagnosis and ICU length of stay were shorter in patients with monomicrobial S. maltophilia HAP (p = 0.031 and p = 0.034 respectively).

Conclusions: S. maltophilia HAP occurred in severe, long-stay intensive care patients who mainly required prolonged invasive ventilation. Empirical antimicrobial therapy was barely effective while antimicrobial treatment modalities had no significant impact on hospital survival.

Trial Registration: clinicaltrials.gov, NCT03506191.
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http://dx.doi.org/10.1186/s13054-019-2649-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873544PMC
November 2019

Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure.

Crit Care 2019 09 6;23(1):306. Epub 2019 Sep 6.

Réanimation DRIS, Hôpital Nord, Marseille, France.

Background: Acute respiratory failure is the leading reason for intensive care unit (ICU) admission in immunocompromised patients, and the need for invasive mechanical ventilation has become a major clinical endpoint in randomized controlled trials (RCTs). However, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. This study explores how this outcome varies across ICUs.

Methods: Hierarchical models and permutation procedures for testing multiple random effects were applied on both data from an observational cohort (the TRIAL-OH study: 703 patients, 17 ICUs) and a randomized controlled trial (the HIGH trial: 776 patients, 31 ICUs) to characterize ICU variation in intubation risk across centers.

Results: The crude intubation rate varied across ICUs from 29 to 80% in the observational cohort and from 0 to 86% in the RCT. This center effect on the mean ICU intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p value = 0.013, median OR 1.48 [1.30-1.72]; RCT: p value 0.004, median OR 1.51 [1.36-1.68]). Two ICU-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to ICU admission) and could partly explain this center effect. In the RCT that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation.

Conclusion: Intubation rates varied considerably among ICUs, even after adjustment on individual characteristics.
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http://dx.doi.org/10.1186/s13054-019-2590-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731598PMC
September 2019

Effect of fluid balance control in critically ill patients: Design of the stepped wedge trial POINCARE-2.

Contemp Clin Trials 2019 08 29;83:109-116. Epub 2019 Jun 29.

Université de Lorraine, CHRU-Nancy, Service de Médecine Intensive Réanimation, F-54000 Nancy, France.

A high number of recent studies have shown that a positive fluid balance is independently associated with impaired prognosis in specific populations of patients hospitalized in intensive care unit (ICU): acute kidney injury, acute respiratory distress syndrome (ARDS), sepsis, high risk surgery. However, to date, there is no evidence that control of fluid overload reduces mortality in critically ill patients. The main objective is to assess the efficacy of a strategy limiting fluid overload on mortality in unselected critically ill patients hospitalized in ICU. We hypothesized that a strategy based on a weight-driven recommendation of restricted fluid intake, diuretics, and ultrafiltration initiated from 48 h up to 14 days after admission in critically ill patients would reduce all-cause mortality as compared to usual care. We use a stepped wedge cluster randomized controlled trial combined with a quasi-experimental (before-and-after) study. Patients under mechanical ventilation, admitted since >48 h and < 72 h in ICU, and with no discharge planned for the next 24 h are eligible. A total of 1440 patients are expected to be enrolled in 12 ICUs. Sociodemographic and clinical data are collected at inclusion, and outcomes are collected during the follow-up. Primary outcome is all-cause mortality at 60 days after admission. Secondary outcomes are patients weight differences between admission and day7 (or day 14), 28-day, in-hospital, and 1-year mortality, end-organ damages, and unintended harmful events. Analyses will be held in intention-to-treat. If POINCARE-2 strategy proves effective, then guidelines on fluid balance control might be extended to all critically ill patients. Trial registration: ClinicalTrials.govNCT02765009.
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http://dx.doi.org/10.1016/j.cct.2019.06.020DOI Listing
August 2019

[Emborrhoid: Rectal arteries embolization for hemorrhoid treatment].

Presse Med 2019 Apr 3;48(4):454-459. Epub 2019 May 3.

Assistance publique-hôpitaux de Marseille, hôpital de la Timone, service d'imagerie diagnostic et interventionnelle, 264, rue Sainte-Pierre, 13005 Marseille, France; Université Aix-Marseille, CERIMED, faculté de médecine, EA 4264, laboratoire d'imagerie interventionnelle expérimentale (LIIE), 27, boulevard Jean-Moulin, 13005 Marseille, France.

Although hemorrhoids are recognized as a very common cause of rectal bleeding and known for a long time, its treatment has evolved dramatically over the last twenty years. Among the new minimally invasive methods, the "Emborrhoid" technique consists into selective embolization of hemorrhoidal arteries, branches arising from the superior rectal arteries using microcoils. This technique is based on a demonstrated pathophysiological concept of arterial network hypertrophy in hemorrhoid disease. This technique was evaluated in an animal model and then in clinical research on more than 100 patients. No ischemic complications were identified. Studies describe an improvement of 60 to 80% of the symptoms, with on average 30% recurrences at two years. The recurrence rae is likely related to a technically incomplete embolization. Future prospects are focused on more selective embolization with Particulate embolic agents.
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http://dx.doi.org/10.1016/j.lpm.2019.04.011DOI Listing
April 2019

Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With Acute Respiratory Failure: The HIGH Randomized Clinical Trial.

JAMA 2018 11;320(20):2099-2107

Department of Anesthesia and Critical Care, Necker Hospital, Paris, France.

Importance: High-flow nasal oxygen therapy is increasingly used for acute hypoxemic respiratory failure (AHRF).

Objective: To determine whether high-flow oxygen therapy decreases mortality among immunocompromised patients with AHRF compared with standard oxygen therapy.

Design, Setting, And Participants: The HIGH randomized clinical trial enrolled 776 adult immunocompromised patients with AHRF (Pao2 <60 mm Hg or Spo2 <90% on room air, or tachypnea >30/min or labored breathing or respiratory distress, and need for oxygen ≥6 L/min) at 32 intensive care units (ICUs) in France between May 19, 2016, and December 31, 2017.

Interventions: Patients were randomized 1:1 to continuous high-flow oxygen therapy (n = 388) or to standard oxygen therapy (n = 388).

Main Outcomes And Measures: The primary outcome was day-28 mortality. Secondary outcomes included intubation and mechanical ventilation by day 28, Pao2:Fio2 ratio over the 3 days after intubation, respiratory rate, ICU and hospital lengths of stay, ICU-acquired infections, and patient comfort and dyspnea.

Results: Of 778 randomized patients (median age, 64 [IQR, 54-71] years; 259 [33.3%] women), 776 (99.7%) completed the trial. At randomization, median respiratory rate was 33/min (IQR, 28-39) vs 32 (IQR, 27-38) and Pao2:Fio2 was 136 (IQR, 96-187) vs 128 (IQR, 92-164) in the intervention and control groups, respectively. Median SOFA score was 6 (IQR, 4-8) in both groups. Mortality on day 28 was not significantly different between groups (35.6% vs 36.1%; difference, -0.5% [95% CI, -7.3% to +6.3%]; hazard ratio, 0.98 [95% CI, 0.77 to 1.24]; P = .94). Intubation rate was not significantly different between groups (38.7% vs 43.8%; difference, -5.1% [95% CI, -12.3% to +2.0%]). Compared with controls, patients randomized to high-flow oxygen therapy had a higher Pao2:Fio2 (150 vs 119; difference, 19.5 [95% CI, 4.4 to 34.6]) and lower respiratory rate after 6 hours (25/min vs 26/min; difference, -1.8/min [95% CI, -3.2 to -0.2]). No significant difference was observed in ICU length of stay (8 vs 6 days; difference, 0.6 [95% CI, -1.0 to +2.2]), ICU-acquired infections (10.0% vs 10.6%; difference, -0.6% [95% CI, -4.6 to +4.1]), hospital length of stay (24 vs 27 days; difference, -2 days [95% CI, -7.3 to +3.3]), or patient comfort and dyspnea scores.

Conclusions And Relevance: Among critically ill immunocompromised patients with acute respiratory failure, high-flow oxygen therapy did not significantly decrease day-28 mortality compared with standard oxygen therapy.

Trial Registration: clinicaltrials.gov Identifier: NCT02739451.
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http://dx.doi.org/10.1001/jama.2018.14282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583581PMC
November 2018

Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis.

N Engl J Med 2018 Oct;379(15):1431-1442

From Réanimation Médicale, Centre Hospitalier Universitaire (CHU) de Nîmes (S.D.B., B. Louart, R.T.), and Saint Eloi, CHU de Montpellier, Université de Montpellier, and INSERM Unité 1046 (S.J.), Service de Réanimation Médicale, CHU Lapeyronie (K.K.), Montpellier, Université de Strasbourg, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg (R.C.-J., F. Meziani, J.H.), Service de Médecine Intensive Réanimation, Hôpital Universitaire François Mitterrand, and Lipness Team, INSERM Research Center Lipids, Nutrition, Cancer-Unité Mixte de Recherche 1231 and Laboratoire d'Excellence LipSTIC (A.D., J.-P.Q.), and Centre d'Investigation Clinique-Epidemiologie Clinique, CHU Dijon-Bourgogne and INSERM Centre d'Investigation Clinique 1432, Université de Bourgogne, Dijon (A.B., C.B., J.-P.Q.), Réanimation Médicale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon (R.H.), Réanimation Polyvalente, Centre Hospitalier d'Avignon, Avignon (F. Montini), Réanimation Polyvalente, Centre Hospitalier de Bourg-en-Bresse, Bourg-en-Bresse (R.B.), Service de Médecine Intensive-Réanimation, Centre Hospitalier de La Roche-sur-Yon, La Roche-sur-Yon (C.L.), Intensive Care Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite (J. Bohé), Réanimation Polyvalente, Hôpital Nord Franche-Comté, Belfort (J. Badie), Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe (J.-P.E., J.-P.R.), Service de Réanimation Médicale, CHU de Nancy-Brabois, Nancy (B. Levy), Service d'Anesthésie-Réanimation, Centre Hospitalier d'Etampes, Etampes (S.S.), Réanimation Polyvalente, Hôpital Bon Secours, Centre Hospitalier Régional de Metz, Metz (G.L.), Infection, Antimicrobiens, Modélisation, Evolution, Unité 1137, Team Decision Sciences in Infectious Disease Prevention, Control, and Care, Université Paris Diderot, Sorbonne Paris Cité, and Medical and Infectious Diseases ICU, Bichat-Claude-Bernard Hospital, Assistance Publique-Hôpitaux de Paris (L.B.), and Service de Réanimation Médicale, Hôpital Cochin (J.-P.M.), Paris, Pôle de Médecine Péri-Opératoire, GReD, and INSERM Unité 1103, CHU Clermont-Ferrand, Clermont-Ferrand (J.-M.C.), Service de Réanimation Médicale, CHU Régional de Tours, Tours (E.M.), CHU de Caen, Service de Réanimation Médicale, Caen (D.C.), Service de Réanimation Médicale (G.P.) and Service de Réanimation Chirurgicale (G.B.), CHU de Besançon, Besançon, Service de Médecine Intensive et Réanimation, Hôpital Raymond Poincaré, Garches (D.A.), Laboratory of Infection and Inflammation, INSERM Unité 1173, University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux (D.A.), Service de Médecine Intensive Réanimation, Groupe des Hôpitaux de l'Institut Catholique de Lille, Université Catholique de Lille, Lille (T.L.), Service de Réanimation Médicale, CHU de Grenoble, Grenoble (C.S.), Service de Réanimation, Centre Hospitalier de Perigueux, Perigueux (L.C.), Service de Réanimation Polyvalente, Centre Hospitalier Général de Mulhouse, Mulhouse (P.G.), Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans (M.-A.N.), and Réanimation Chirurgicale-CHU de Nîmes, Nîmes (C.R.) - all in France.

Background: Acute kidney injury is the most frequent complication in patients with septic shock and is an independent risk factor for death. Although renal-replacement therapy is the standard of care for severe acute kidney injury, the ideal time for initiation remains controversial.

Methods: In a multicenter, randomized, controlled trial, we assigned patients with early-stage septic shock who had severe acute kidney injury at the failure stage of the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification system but without life-threatening complications related to acute kidney injury to receive renal-replacement therapy either within 12 hours after documentation of failure-stage acute kidney injury (early strategy) or after a delay of 48 hours if renal recovery had not occurred (delayed strategy). The failure stage of the RIFLE classification system is characterized by a serum creatinine level 3 times the baseline level (or ≥4 mg per deciliter with a rapid increase of ≥0.5 mg per deciliter), urine output less than 0.3 ml per kilogram of body weight per hour for 24 hours or longer, or anuria for at least 12 hours. The primary outcome was death at 90 days.

Results: The trial was stopped early for futility after the second planned interim analysis. A total of 488 patients underwent randomization; there were no significant between-group differences in the characteristics at baseline. Among the 477 patients for whom follow-up data at 90 days were available, 58% of the patients in the early-strategy group (138 of 239 patients) and 54% in the delayed-strategy group (128 of 238 patients) had died (P=0.38). In the delayed-strategy group, 38% (93 patients) did not receive renal-replacement therapy. Criteria for emergency renal-replacement therapy were met in 17% of the patients in the delayed-strategy group (41 patients).

Conclusions: Among patients with septic shock who had severe acute kidney injury, there was no significant difference in overall mortality at 90 days between patients who were assigned to an early strategy for the initiation of renal-replacement therapy and those who were assigned to a delayed strategy. (Funded by the French Ministry of Health; IDEAL-ICU ClinicalTrials.gov number, NCT01682590 .).
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http://dx.doi.org/10.1056/NEJMoa1803213DOI Listing
October 2018

Disseminated intravascular coagulation in pneumococcemia.

Intensive Care Med 2019 05 20;45(5):698-699. Epub 2018 Aug 20.

Hopital de Mercy service de réanimation polyvalente CHR Metz-Thionville, Ars-Laquenexy, France.

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http://dx.doi.org/10.1007/s00134-018-5340-4DOI Listing
May 2019

Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction.

J Am Coll Cardiol 2018 07;72(2):173-182

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

Background: Vasopressor agents could have certain specific effects in patients with cardiogenic shock (CS) after myocardial infarction, which may influence outcome. Although norepinephrine and epinephrine are currently the most commonly used agents, no randomized trial has compared their effects, and intervention data are lacking.

Objectives: The goal of this paper was to compare in a prospective, double-blind, multicenter, randomized study, the efficacy and safety of epinephrine and norepinephrine in patients with CS after acute myocardial infarction.

Methods: The primary efficacy outcome was cardiac index evolution, and the primary safety outcome was the occurrence of refractory CS. Refractory CS was defined as CS with sustained hypotension, end-organ hypoperfusion and hyperlactatemia, and high inotrope and vasopressor doses.

Results: Fifty-seven patients were randomized into 2 study arms, epinephrine and norepinephrine. For the primary efficacy endpoint, cardiac index evolution was similar between the 2 groups (p = 0.43) from baseline (H0) to H72. For the main safety endpoint, the observed higher incidence of refractory shock in the epinephrine group (10 of 27 [37%] vs. norepinephrine 2 of 30 [7%]; p = 0.008) led to early termination of the study. Heart rate increased significantly with epinephrine from H2 to H24 while remaining unchanged with norepinephrine (p < 0.0001). Several metabolic changes were unfavorable to epinephrine compared with norepinephrine, including an increase in cardiac double product (p = 0.0002) and lactic acidosis from H2 to H24 (p < 0.0001).

Conclusions: In patients with CS secondary to acute myocardial infarction, the use of epinephrine compared with norepinephrine was associated with similar effects on arterial pressure and cardiac index and a higher incidence of refractory shock. (Study Comparing the Efficacy and Tolerability of Epinephrine and Norepinephrine in Cardiogenic Shock [OptimaCC]; NCT01367743).
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http://dx.doi.org/10.1016/j.jacc.2018.04.051DOI Listing
July 2018

Embolization of the Superior Rectal Arteries for Hemorrhoidal Disease: Prospective Results in 25 Patients.

J Vasc Interv Radiol 2018 06 30;29(6):884-892.e1. Epub 2018 Apr 30.

Department of Interventional Radiology, Marseille Public University Hospital System, La Timone University Hospital, 264 Rue Saint Pierre, Marseille 13385, Cedex 05, France; Experimental Interventional Imaging Laboratory, Aix Marseille University, Marseille, France.

Purpose: To evaluate efficacy and safety of superior rectal artery embolization of hemorrhoidal disease as a first-line invasive treatment.

Materials And Methods: This prospective study was conducted between 2014 and 2015 on 25 consecutive patients (16 men and 9 women with a mean age of 53 y [range, 30-76 y]) with grade II-III hemorrhoids refractory to medical treatment. A transfemoral superselective superior rectal artery branch embolization was performed using 2- and 3-mm diameter microcoils. Over the following 12 months, clinical outcomes were evaluated using the French bleeding score, Goligher prolapse score, visual analog scale (VAS) score for pain, quality-of-life score. The primary endpoint was relief of symptoms by 12 months based on a 2-point minimum improvement on VAS score and bleeding score.

Results: At 12 months after embolization, clinical success was obtained in 18 patients (72%), 8 of whom had 2 embolizations. VAS score decreased from 4.6 to 2.3 (P < .01), and bleeding score decreased from 5.5 to 2.3 (P < .01). Quality-of-life and prolapse scores also showed improvement (P < .05), and no patients experienced any early or late complications. Complete clinical failure was observed in 7 patients. After coil embolization, the collateral supply to the hemorrhoidal cushions was significantly related to any recurrence (P = .001).

Conclusions: Hemorrhoidal artery coil embolization was found to be a safe and effective treatment for grade II-III hemorrhoids.
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http://dx.doi.org/10.1016/j.jvir.2018.01.778DOI Listing
June 2018

High-flow nasal oxygen vs. standard oxygen therapy in immunocompromised patients with acute respiratory failure: study protocol for a randomized controlled trial.

Trials 2018 Mar 5;19(1):157. Epub 2018 Mar 5.

Réanimation des Détresses Respiratoires et Infections Sévères, Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Aix-Marseille Université, Faculté de Médecine, Marseille, France.

Background: Acute respiratory failure (ARF) is the leading reason for intensive care unit (ICU) admission in immunocompromised patients. High-flow nasal oxygen (HFNO) therapy is an alternative to standard oxygen. By providing warmed and humidified gas, HFNO allows the delivery of higher flow rates via nasal cannula devices, with FiO values of nearly 100%. Benefits include alleviation of dyspnea and discomfort, decreased respiratory distress and decreased mortality in unselected patients with acute hypoxemic respiratory failure. However, in preliminary reports, HFNO benefits are controversial in immunocompromised patients in whom it has never been properly evaluated.

Methods/design: This is a multicenter, open-label, randomized controlled superiority trial in 30 intensive care units, part of the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (GRRR-OH). Inclusion criteria will be: (1) adults, (2) known immunosuppression, (3) ARF, (4) oxygen therapy ≥ 6 L/min, (5) written informed consent from patient or proxy. Exclusion criteria will be: (1) imminent death (moribund patient), (2) no informed consent, (3) hypercapnia (PaCO ≥ 50 mmHg), (4) isolated cardiogenic pulmonary edema, (5) pregnancy or breastfeeding, (6) anatomical factors precluding insertion of a nasal cannula, (7) no coverage by the French statutory healthcare insurance system, and (8) post-surgical setting from day 1 to day 6 (patients with ARF occurring after day 6 of surgery can be included). The primary outcome measure is day-28 mortality. Secondary outcomes are intubation rate, comfort, dyspnea, respiratory rate, oxygenation, ICU length of stay, and ICU-acquired infections. Based on an expected 30% mortality rate in the standard oxygen group, and 20% in the HFNO group, error rate set at 5%, and a statistical power at 90%, 389 patients are required in each treatment group (778 patients overall). Recruitment period is estimated at 30 months, with 28 days of additional follow-up for the last included patient.

Discussion: The HIGH study will be the largest multicenter, randomized controlled trial seeking to demonstrate that survival benefits from HFNO reported in unselected patients also apply to a large immunocompromised population.

Trial Registration: ClinicalTrials.gov, ID: NCT02739451 . Registered on 15 April 2016.
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http://dx.doi.org/10.1186/s13063-018-2492-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836389PMC
March 2018

Embolisation of pulmonary radio frequency pathway - a randomised trial.

Int J Hyperthermia 2017 11 23;33(7):814-819. Epub 2017 Apr 23.

a Hopital de la Timone , Marseille , France.

Purpose: Pneumothorax is the most common complication following a pulmonary percutaneous radiofrequency ablation (RFA), and thoracic drainages are the most frequent causes of an extended hospital stay. Our main objective was to show that the use of gelatin torpedoes may significantly decrease the number of chest tube placement.

Materials And Methods: Seventy-three patients were prospectively included in this study and then randomised into two groups: 34 with embolisation and without 39 without embolisation. Each group was comparable for different pneumothorax risk factors.

Results: There were 16 (47%) pneumothorax in Group A ("with embolisation"), which was significantly lower (p < .0001) than the 35 pneumothorax (90%) in Group B ("without embolisation"). The pneumothorax volume (p = .02) was significantly lower in Group A (22.7% average, standard deviation 15.6%) than in Group B (average 34.1%, standard deviation 17.1%). The number of drainages was significantly smaller in those with embolisation (3 drainages or 8%) than those without embolisation (25 drainages or 64%) (p < .001).

Conclusion: When using absorbable gelatin torpedoes, pulmonary RFA pathways embolisation significantly decreased the number of pneumothorax and thoracic drainages to the advantage of therapeutic abstention and exsufflation, non-invasive and functional operational techniques.
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http://dx.doi.org/10.1080/02656736.2017.1309578DOI Listing
November 2017

Functional outcome of patients with prolonged hypoglycemic encephalopathy.

Ann Intensive Care 2017 Dec 22;7(1):54. Epub 2017 May 22.

Service de Réanimation médicale, Hôpital Central, CHU de Nancy, Av. de Lattre de Tassigny, 54035, Nancy Cedex, France.

Background: Little is known about the causes, clinical course and long-term outcome of comatose patients with prolonged hypoglycemic encephalopathy.

Methods: In a multicenter retrospective study conducted in patients hospitalized from July 1, 2004, to July 1, 2014, we investigated functional long-term prognosis and identified prognosis factors of patients admitted in an intensive care unit (ICU) with prolonged neurological manifestations related to hypoglycemia. Eligible patients were adults admitted to the ICU with a Glasgow Coma Score <8 due to hypoglycemia and persistent consciousness disorders after normalizing blood glucose levels. Patients with possible other causes of consciousness disorders, previous cognitive disorders, hypothermia <35 °C or circulatory arrest within 24 h after ICU admission, were excluded. Follow-up phone call was used to determine patients' functional outcome using modified Rankin Scale (mRS) at a minimum of 1-year follow-up with mRS 0-3 defining good and mRS 4-6 poor outcomes.

Results: Forty-nine patients were included. Causes of hypoglycemia were various, mainly including insulin or oral antidiabetic drugs abuse (65%) and neuroendocrine carcinoma (16%). Twenty (41%) patients died in the ICU, two (4%) patients further died and nine (18%) patients had a poor outcome at long-term follow-up. Five patients discharged from the ICU with mRS > 3 improved enough to be in the good outcome group 1 year later. Twenty-two (45%) patients underwent therapeutic limitation, mainly related to no expected hope for improvement. On multivariate analysis, only low mRS prior to ICU admission (OR 2.6; 95% CI 1.1-6.3; P = 0.03) and normal brain imaging (OR 7.1; 95% CI 1.1-44; P = 0.03) were significantly predictive of a good outcome. All patients (n = 15) who remained hypoglycemic >480 min had a poor outcome.

Conclusion: Poor outcome was observed in about 60% of this population of hypoglycemic encephalopathy. However, some patients can recover satisfactorily over time.
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http://dx.doi.org/10.1186/s13613-017-0277-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440422PMC
December 2017

Grey Turner's sign associated with hemorrhagic pancreatitis.

Intensive Care Med 2017 Feb 30;43(2):265-266. Epub 2016 Sep 30.

Service de Réanimation Polyvalente, Hôpital de Mercy, CHR Metz-Thionville, 1 Allée Du Château, 57530, Ars-Laquenexy, France.

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http://dx.doi.org/10.1007/s00134-016-4551-9DOI Listing
February 2017

Successful liver transplantation for hepatocellular carcinoma following down-staging using sorafenib single therapy.

Liver Int 2016 09 8;36(9):1393. Epub 2016 Jul 8.

Department of Hepato-Gastroenterology, Hôpital de la Timone, Aix-Marseille Université, Marseille Cedex 5, France.

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http://dx.doi.org/10.1111/liv.13190DOI Listing
September 2016

Outcomes of patients admitted to intensive care units for acute manifestation of small-vessel vasculitis: a multicenter, retrospective study.

Crit Care 2016 Jan 26;20:27. Epub 2016 Jan 26.

Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France.

Background: The outcomes of patients admitted to the intensive care unit (ICU) for acute manifestation of small-vessel vasculitis are poorly reported. The aim of the present study was to determine the mortality rate and prognostic factors of patients admitted to the ICU for acute small-vessel vasculitis.

Methods: This retrospective, multicenter study was conducted from January 2001 to December 2014 in 20 ICUs in France. Patients were identified from computerized registers of each hospital using the International Classification of Diseases, Ninth Revision (ICD-9). Inclusion criteria were (1) known or highly suspected granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis (respectively, ICD-9 codes M31.3, M30.1, and M31.7), or anti-glomerular basement membrane antibody disease (ICD-9 codes N08.5X-005 or M31.0+); (2) admission to the ICU for the management of an acute manifestation of vasculitis; and (3) administration of a cyclophosphamide pulse in the ICU or within 48 h before admission to the ICU. The primary endpoint was assessment of mortality rate 90 days after admission to the ICU.

Results: Eighty-two patients at 20 centers were included, 94% of whom had a recent (<6 months) diagnosis of small-vessel vasculitis. Forty-four patients (54%) had granulomatosis with polyangiitis. The main reasons for admission were respiratory failure (34%) and pulmonary-renal syndrome (33%). Mechanical ventilation was required in 51% of patients, catecholamines in 31%, and renal replacement therapy in 71%. Overall mortality at 90 days was 18% and the mortality in ICU was 16 %. The main causes of death in the ICU were disease flare in 69% and infection in 31%. In univariable analysis, relevant factors associated with death in nonsurvivors compared with survivors were Simplified Acute Physiology Score II (median [interquartile range] 51 [38-82] vs. 36 [27-42], p = 0.005), age (67 years [62-74] vs. 58 years [40-68], p < 0.003), Sequential Organ Failure Assessment score on the day of cyclophosphamide administration (11 [6-12] vs. 6 [3-7], p = 0.0004), and delayed administration of cyclophosphamide (5 days [3-14] vs. 2 days [1-5], p = 0.0053).

Conclusions: Patients admitted to the ICU for management of acute small-vessel vasculitis benefit from early, aggressive intensive care treatment, associated with an 18% death rate at 90 days.
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http://dx.doi.org/10.1186/s13054-016-1189-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4729170PMC
January 2016
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