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Winiszewski H, Vieille T, Guinot PG, Nesseler N, Le Berre M, Crognier L, Roche AC, Fellahi JL, D'Ostrevy N, Ltaief Z, Didier J, Arab OA, Meslin S, Scherrer V, Besch G, Monnier A, Piton G, Kimmoun A, Capellier G. Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study. Ann Intensive Care 2024; 14:56. [PMID: 38597975 PMCID: PMC11006645 DOI: 10.1186/s13613-024-01286-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGOUND Hyperoxemia is common and associated with poor outcome during veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. However, little is known about practical daily management of oxygenation. Then, we aim to describe sweep gas oxygen fraction (FSO2), postoxygenator oxygen partial pressure (PPOSTO2), inspired oxygen fraction (FIO2), and right radial arterial oxygen partial pressure (PaO2) between day 1 and day 7 of peripheral VA ECMO support. We also aim to evaluate the association between oxygenation parameters and outcome. In this retrospective multicentric study, each participating center had to report data on the last 10 eligible patients for whom the ICU stay was terminated. Patients with extracorporeal cardiopulmonary resuscitation were excluded. Primary endpoint was individual mean FSO2 during the seven first days of ECMO support (FSO2 mean (day 1-7)). RESULTS Between August 2019 and March 2022, 139 patients were enrolled in 14 ECMO centers in France, and one in Switzerland. Among them, the median value for FSO2 mean (day 1-7) was 70 [57; 79] % but varied according to center case volume. Compared to high volume centers, centers with less than 30 VA-ECMO runs per year were more likely to maintain FSO2 ≥ 70% (OR 5.04, CI 95% [1.39; 20.4], p = 0.017). Median value for right radial PaO2 mean (day 1-7) was 114 [92; 145] mmHg, and decreased from 125 [86; 207] mmHg at day 1, to 97 [81; 133] mmHg at day 3 (p < 0.01). Severe hyperoxemia (i.e. right radial PaO2 ≥ 300 mmHg) occurred in 16 patients (12%). PPOSTO2, a surrogate of the lower body oxygenation, was measured in only 39 patients (28%) among four centers. The median value of PPOSTO2 mean (day 1-7) value was 198 [169; 231] mmHg. By multivariate analysis, age (OR 1.07, CI95% [1.03-1.11], p < 0.001), FSO2 mean (day 1-3)(OR 1.03 [1.00-1.06], p = 0.039), and right radial PaO2 mean (day 1-3) (OR 1.03, CI95% [1.00-1.02], p = 0.023) were associated with in-ICU mortality. CONCLUSION In a multicentric cohort of cardiogenic shock supported by VA ECMO, the median value for FSO2 mean (day 1-7) was 70 [57; 79] %. PPOSTO2 monitoring was infrequent and revealed significant hyperoxemia. Higher FSO2 mean (day 1-3) and right radial PaO2 mean (day 1-3) were independently associated with in-ICU mortality.
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Affiliation(s)
- Hadrien Winiszewski
- Service de réanimation médicale, CHU Besançon, Besançon, France.
- Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France.
| | | | | | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, University Hospital of Rennes, Pontchaillou, Rennes, France
| | - Mael Le Berre
- Service de réanimation médicale, CHU Besançon, Besançon, France
| | - Laure Crognier
- Intensive Care Unit, Anesthesia and Critical Care Department, Rangueil University Hospital, Toulouse, France
| | - Anne-Claude Roche
- Anesthesia, Intensive Care and Perioperative Medicine, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Nicolas D'Ostrevy
- Cardiac Surgery Department, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Zied Ltaief
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, Lausanne, 1011, Switzerland
| | - Juliette Didier
- Service de médecine intensive réanimation, CHU Pitié Salpêtrière, Paris, France
| | - Osama Abou Arab
- Department of Anaesthesia and Critical Care Medicine, Amiens University Medical Center, Amiens, France
| | - Simon Meslin
- Anesthesiology and Critical Care Medicine Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Vincent Scherrer
- Department of Anaesthesiology and Critical Care, CHU Rouen, Rouen, F-76000, France
| | - Guillaume Besch
- Département d'Anesthésie Réanimation Chirurgicale, Université de Franche-Comté, CHU Besançon, CIC Inserm 1431, Besançon, EA3920, F-25000, France
| | - Alexandra Monnier
- Service de Médecine Intensive-Réanimation Médicale, CHU Strasbourg, Nouvel Hôpital Civil, Université de Strasbourg, Strasbourg, 67000, France
| | - Gael Piton
- Service de réanimation médicale, CHU Besançon, Besançon, France
| | - Antoine Kimmoun
- Service de médecine intensive réanimation, CHU Nancy, Créteil, France
| | - Gilles Capellier
- Service de réanimation médicale, CHU Besançon, Besançon, France
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia
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Premraj L, Brown A, Fraser JF, Pellegrino V, Pilcher D, Burrell A. Oxygenation During Venoarterial Extracorporeal Membrane Oxygenation: Physiology, Current Evidence, and a Pragmatic Approach to Oxygen Titration. Crit Care Med 2024; 52:637-648. [PMID: 38059745 DOI: 10.1097/ccm.0000000000006134] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES This review aims to: 1) identify the key circuit and patient factors affecting systemic oxygenation, 2) summarize the literature reporting the association between hyperoxia and patient outcomes, and 3) provide a pragmatic approach to oxygen titration, in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (ECMO). DATA SOURCES Searches were performed using PubMed, SCOPUS, Medline, and Google Scholar. STUDY SELECTION All observational and interventional studies investigating the association between hyperoxia, and clinical outcomes were included, as well as guidelines from the Extracorporeal Life Support Organization. DATA EXTRACTION Data from relevant literature was extracted, summarized, and integrated into a concise narrative review. For ease of reference a summary of relevant studies was also produced. DATA SYNTHESIS The extracorporeal circuit and the native cardiorespiratory circuit both contribute to systemic oxygenation during venoarterial ECMO. The ECMO circuit's contribution to systemic oxygenation is, in practice, largely determined by the ECMO blood flow, whereas the native component of systemic oxygenation derives from native cardiac output and residual respiratory function. Interactions between ECMO outflow and native cardiac output (as in differential hypoxia), the presence of respiratory support, and physiologic parameters affecting blood oxygen carriage also modulate overall oxygen exposure during venoarterial ECMO. Physiologically those requiring venoarterial ECMO are prone to hyperoxia. Hyperoxia has a variety of definitions, most commonly Pa o2 greater than 150 mm Hg. Severe hypoxia (Pa o2 > 300 mm Hg) is common, seen in 20%. Early severe hyperoxia, as well as cumulative hyperoxia exposure was associated with in-hospital mortality, even after adjustment for disease severity in both venoarterial ECMO and extracorporeal cardiopulmonary resuscitation. A pragmatic approach to oxygenation during peripheral venoarterial ECMO involves targeting a right radial oxygen saturation target of 94-98%, and in selected patients, titration of the fraction of oxygen in the mixture via the air-oxygen blender to target postoxygenator Pa o2 of 150-300 mm Hg. CONCLUSIONS Hyperoxia results from a range of ECMO circuit and patient-related factors. It is common during peripheral venoarterial ECMO, and its presence is associated with poor outcome. A pragmatic approach that avoids hyperoxia, while also preventing hypoxia has been described for patients receiving peripheral venoarterial ECMO.
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Affiliation(s)
- Lavienraj Premraj
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Alastair Brown
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Vincent Pellegrino
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Aidan Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
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Kharnaf M, Abplanalp WA, Young C, Sprague C, Rosenfeldt L, Smith R, Wang D, Palumbo JS, Morales DLS. Unmasking the Impact of Oxygenator Induced Hypocapnia on Blood Lactate in Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2024:00002480-990000000-00443. [PMID: 38483814 DOI: 10.1097/mat.0000000000002191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is often associated with disturbances in acid/base status that can be triggered by the underlying pathology or the ECMO circuit itself. Extracorporeal membrane oxygenation is known to cause hypocapnia, but the impact of reduced partial pressure of carbon dioxide (pCO2) on biomarkers of tissue perfusion during veno-arterial (VA)-ECMO has not been evaluated. To study the impact of low pCO2 on perfusion indices in VA-ECMO, we placed Sprague-Dawley rats on an established VA-ECMO circuit using either an oxygen/carbon dioxide mixture (O2 95%, CO2 5%) or 100% O2 delivered through the oxygenator (n = 5 per cohort). Animals receiving 100% O2 developed a significant VA CO2 difference (pCO2 gap) and rising blood lactate levels that were inversely proportional to the decrease in pCO2 values. In contrast, pCO2 gap and lactate levels remained similar to pre-ECMO baseline levels in animals receiving the O2/CO2 mixture. More importantly, there was no significant difference in venous oxygen saturation (SvO2) between the two groups, suggesting that elevated blood lactate levels observed in the rats receiving 100% O2 were a response to oxygenator induced hypocapnia and alkaline pH rather than reduced perfusion or underlying tissue hypoxia. These findings have implications in clinical and experimental extracorporeal support contexts.
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Affiliation(s)
- Mousa Kharnaf
- From the The Heart Institute, Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, and The University of Cincinnati College of Medicine, Cincinnati Ohio
| | - William A Abplanalp
- From the The Heart Institute, Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, and The University of Cincinnati College of Medicine, Cincinnati Ohio
| | - Courtney Young
- Cancer and Blood Disease Institute, Division of Hematology,Cincinnati Children's Hospital Medical Center, and The University of Cincinnati College of Medicine, Cincinnati Ohio
| | - Cassandra Sprague
- Cancer and Blood Disease Institute, Division of Hematology,Cincinnati Children's Hospital Medical Center, and The University of Cincinnati College of Medicine, Cincinnati Ohio
| | - Leah Rosenfeldt
- Cancer and Blood Disease Institute, Division of Hematology,Cincinnati Children's Hospital Medical Center, and The University of Cincinnati College of Medicine, Cincinnati Ohio
| | - Reanna Smith
- ECMO Program, Patient Services Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dongfang Wang
- Division of Surgical Research, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Joseph S Palumbo
- Cancer and Blood Disease Institute, Division of Hematology,Cincinnati Children's Hospital Medical Center, and The University of Cincinnati College of Medicine, Cincinnati Ohio
| | - David L S Morales
- From the The Heart Institute, Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, and The University of Cincinnati College of Medicine, Cincinnati Ohio
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Meuwese CL, Brodie D, Donker DW. The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation. Crit Care 2022; 26:216. [PMID: 35841052 PMCID: PMC9284848 DOI: 10.1186/s13054-022-04089-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractVenoarterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly applied in patients with cardiogenic shock in recent years. Nevertheless, many patients cannot be successfully weaned from VA ECMO support and 1-year mortality remains high. A systematic approach could help to optimize clinical management in favor of weaning by identifying important factors in individual patients. Here, we provide an overview of pivotal factors that potentially prevent successful weaning of VA ECMO. We present this through a rigorous approach following the relatable acronym ABCDE, in order to facilitate widespread use in daily practice.
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Andrei S, Nguyen M, Berthoud V, Durand B, Duclos V, Morgant MC, Bouchot O, Bouhemad B, Guinot PG. Determinants of Arterial Pressure of Oxygen and Carbon Dioxide in Patients Supported by Veno-Arterial ECMO. J Clin Med 2022; 11:jcm11175228. [PMID: 36079158 PMCID: PMC9457238 DOI: 10.3390/jcm11175228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The present study aimed to assess the determinants of arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2) in the early phase of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Even though the guidelines considered both the risks of hypoxemia and hyperoxemia during ECMO support, there are a lack of data concerning the patients supported by VA ECMO. Methods: This is a retrospective, monocentric, observational cohort study in a university-affiliated cardiac intensive care unit. Hemodynamic parameters, ECMO parameters, ventilator settings, and blood gas analyses were collected at several time points during the first 48 h of VA ECMO support. For each timepoint, the blood samples were drawn simultaneously from the right radial artery catheter, VA ECMO venous line (before the oxygenator), and from VA ECMO arterial line (after the oxygenator). Univariate followed by multivariate mixed-model analyses were performed for longitudinal data analyses. Results: Forty-five patients with femoro-femoral peripheral VA ECMO were included. In multivariate analysis, the patients' PaO2 was independently associated with QEC, FDO2, and time of measurement. The patients' PaCO2 was associated with the sweep rate flow and the PpreCO2. Conclusions: During acute VA ECMO support, the main determinants of patient oxygenation are determined by VA ECMO parameters.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
- Correspondence: ; Tel.: +33-38-029-3031
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Bastian Durand
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Valerian Duclos
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | | | - Olivier Bouchot
- Cardiac Surgery Department, Dijon University Hospital, F-21000 Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
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Winiszewski H, Guinot PG, Schmidt M, Besch G, Piton G, Perrotti A, Lorusso R, Kimmoun A, Capellier G. Optimizing PO 2 during peripheral veno-arterial ECMO: a narrative review. Crit Care 2022; 26:226. [PMID: 35883117 PMCID: PMC9316319 DOI: 10.1186/s13054-022-04102-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/13/2022] [Indexed: 01/01/2023] Open
Abstract
During refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (PPOSTO2) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this PPOSTO2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (FSO2). Because of the oxygenator's performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO2) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting FSO2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of PPOSTO2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.
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Affiliation(s)
- Hadrien Winiszewski
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France. .,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France.
| | - Pierre-Grégoire Guinot
- Service d'Anesthésie-Réanimation Chirurgicale, centre hospitalier universitaire de Dijon, Dijon, France
| | - Matthieu Schmidt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Besch
- Service d'Anesthésie-Réanimation Chirurgicale, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Gael Piton
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Andrea Perrotti
- Service de Chirurgie Cardiaque, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Antoine Kimmoun
- Service de Médecine Intensive Réanimation, centre hospitalier universitaire de Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - Gilles Capellier
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
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