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Genty T, Burguburu S, Imbert A, Roman C, Camille W, Thès J, Stéphan F. Circuit change during extracorporeal membrane oxygenation: single-center retrospective study of 48 changes. Crit Care 2023; 27:219. [PMID: 37269022 DOI: 10.1186/s13054-023-04503-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/20/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Bleeding and thrombosis induce major morbidity and mortality in patients under extracorporeal membrane oxygenator (ECMO). Circuit changes can be performed for oxygenation membrane thrombosis but are not recommended for bleeding under ECMO. The objective of this study was to evaluate the course of clinical, laboratory, and transfusion parameters before and after ECMO circuit changes warranted by bleeding or thrombosis. METHODS In this single-center, retrospective, cohort study, clinical parameters (bleeding syndrome, hemostatic procedures, oxygenation parameters, transfusion) and laboratory parameters (platelet count, hemoglobin, fibrinogen, PaO2) were collected over the seven days surrounding the circuit change. RESULTS In the 274 patients on ECMO from January 2017 to August 2020, 48 circuit changes were performed in 44 patients, including 32 for bleeding and 16 for thrombosis. Mortality was similar in the patients with vs. without changes (21/44, 48% vs. 100/230, 43%) and in those with bleeding vs. thrombosis (12/28, 43% vs. 9/16, 56%, P = 0.39). In patients with bleeding, numbers of bleeding events, hemostatic procedures, and red blood cell transfusions were significantly higher before vs. after the change (P < 0.001); the platelet counts and fibrinogen levels decreased progressively before and increased significantly after the change. In patients with thrombosis, numbers of bleeding events and red blood cell transfusions did not change after membrane change. No significant differences were demonstrated between oxygenation parameters (ventilator FiO2, ECMO FiO2, and PaO2) and ECMO flow before vs. after the change. CONCLUSIONS In patients with severe and persistent bleeding, changing the ECMO circuit decreased clinical bleeding and red blood cell transfusion needs and increased platelets and fibrinogen levels. Oxygenation parameters did not change significantly in the group with thrombosis.
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Affiliation(s)
- Thibaut Genty
- Cardiothoracic Intensive Care Unit, Hôpital Marie LannelongueGroupe Hospitalier Paris Saint Joseph, 133 Avenue de La Résistance, 92350, Le Plessis-Robinson, France.
| | - Stanislas Burguburu
- Cardiothoracic Intensive Care Unit, Hôpital Marie LannelongueGroupe Hospitalier Paris Saint Joseph, 133 Avenue de La Résistance, 92350, Le Plessis-Robinson, France
| | - Audrey Imbert
- Cardiothoracic Intensive Care Unit, Hôpital Marie LannelongueGroupe Hospitalier Paris Saint Joseph, 133 Avenue de La Résistance, 92350, Le Plessis-Robinson, France
| | - Calypso Roman
- Cardiothoracic Intensive Care Unit, Hôpital Marie LannelongueGroupe Hospitalier Paris Saint Joseph, 133 Avenue de La Résistance, 92350, Le Plessis-Robinson, France
| | - Wirth Camille
- Cardiothoracic Intensive Care Unit, Hôpital Marie LannelongueGroupe Hospitalier Paris Saint Joseph, 133 Avenue de La Résistance, 92350, Le Plessis-Robinson, France
| | - Jacques Thès
- Department of Anesthesiology, Extracorporeal Circulation Referral Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Hôpital Marie LannelongueGroupe Hospitalier Paris Saint Joseph, 133 Avenue de La Résistance, 92350, Le Plessis-Robinson, France
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
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Diop S, Djebbour M, Stéphan F, Genty T. Popliteal Sciatic Nerve Block as Rescue Therapy in Acute Lower Limb Ischemia Related to Venoarterial ECMO Support. J Cardiothorac Vasc Anesth 2023; 37:191-192. [PMID: 36272930 DOI: 10.1053/j.jvca.2022.09.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Sylvain Diop
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France; Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis Robinson, France.
| | - Maxime Djebbour
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France; University Paris-Saclay, Kremlin-Bicêtre, France; INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | - Thibaut Genty
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Rezaiguia-Delclaux S, Ren L, Gruner A, Roman C, Genty T, Stéphan F. Oxygenation versus driving pressure for determining the best positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care 2022; 26:214. [PMID: 35831827 PMCID: PMC9281138 DOI: 10.1186/s13054-022-04084-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/29/2022] [Indexed: 12/16/2022] Open
Abstract
Objective The aim of this prospective longitudinal study was to compare driving pressure and absolute PaO2/FiO2 ratio in determining the best positive end-expiratory pressure (PEEP) level. Patients and methods In 122 patients with acute respiratory distress syndrome, PEEP was increased until plateau pressure reached 30 cmH2O at constant tidal volume, then decreased at 15-min intervals, to 15, 10, and 5 cmH2O. The best PEEP by PaO2/FiO2 ratio (PEEPO2) was defined as the highest PaO2/FiO2 ratio obtained, and the best PEEP by driving pressure (PEEPDP) as the lowest driving pressure. The difference between the best PEEP levels was compared to a non-inferiority margin of 1.5 cmH2O. Main results The best mean PEEPO2 value was 11.9 ± 4.7 cmH2O compared to 10.6 ± 4.1 cmH2O for the best PEEPDP: mean difference = 1.3 cmH2O (95% confidence interval [95% CI], 0.4–2.3; one-tailed P value, 0.36). Only 46 PEEP levels were the same with the two methods (37.7%; 95% CI 29.6–46.5). PEEP level was ≥ 15 cmH2O in 61 (50%) patients with PEEPO2 and 39 (32%) patients with PEEPDP (P = 0.001). Conclusion Depending on the method chosen, the best PEEP level varies. The best PEEPDP level is lower than the best PEEPO2 level. Computing driving pressure is simple, faster and less invasive than measuring PaO2. However, our results do not demonstrate that one method deserves preference over the other in terms of patient outcome. Clinical trial number: #ACTRN12618000554268. Registered 13 April 2018.
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Kortchinsky T, Genty T, Gigandon A, Roman C, Rézaiguia-Delclaux S, Stéphan F. Including Organ Dysfunctions in a Predictive Score for Nosocomial Pneumonia After Cardiothoracic Surgery. Respir Care 2022; 67:1558-1567. [PMID: 36100277 PMCID: PMC9994026 DOI: 10.4187/respcare.09911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinical diagnosis of ICU-acquired pneumonia after cardiothoracic surgery is challenging. Johanson criteria (chest radiograph infiltrate, purulent tracheal secretions, fever, and leukocytosis) fail in half the cases. A high Clinical Pulmonary Infection Score (CPIS) and ≥ 2-point increase in Sequential Organ Failure Assessment (SOFA) score (SOFA↑ ≥ 2) may improve diagnosis. The aim of the study was to evaluate whether CPIS or SOFA↑ ≥ 2 contributes to predict ICU-acquired pneumonia in subjects after cardiothoracic surgery. METHODS We used a prospective observational design. Spiegelhalter-Knill-Jones scoring systems including CPIS or SOFA↑ ≥ 2, together with other clinical and laboratory variables, were developed in a derivation cohort. A positive quantitative pulmonary sample culture was required to confirm ICU-acquired pneumonia. Area under the receiver operating characteristic curve (AUROC) was computed for each of the 2 scoring systems. The best system was evaluated in a validation cohort. RESULTS Derivation and validation cohorts included 172 and 108 subjects, with 410 and 216 suspected ICU-acquired pneumonia episodes, respectively. AUROC was 0.53 ± 0.03 for CPIS (P = .29) and 0.54 ± 0.03 for SOFA↑ ≥ 2 (P = .29). Adding purulent tracheal secretions and leukocytosis to SOFA↑ ≥ 2 (SOFA model) increased AUROC to 0.65 ± 0.03 (P < .001). Adding catecholamine use to CPIS (CPIS model) increased AUROC only slightly, to 0.57 ± 0.03. The probabilities predicted by the SOFA model were reliable, especially when high or low. CONCLUSIONS A clinical scoring system including at least SOFA↑ ≥ 2 increase barely improved ICU-acquired pneumonia prediction in subjects after cardiothoracic surgery.
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Affiliation(s)
- Talna Kortchinsky
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Thibaut Genty
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Anne Gigandon
- Bacteriology Laboratory, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Calypso Roman
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | | | - François Stéphan
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France; and Paris Saclay University, School of Medicine, Le Kremlin Bicêtre, France.
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Imbert A, Sigal-Cinqualbre A, Genty T, Stéphan F. A Heart Transplant Patient With Fever, Diarrhea, and Neutropenia. Clin Infect Dis 2022; 75:1109-1110. [PMID: 36174247 DOI: 10.1093/cid/ciab894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Audrey Imbert
- Adult Intensive Care Unit, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Anne Sigal-Cinqualbre
- Radiology Department, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Thibaut Genty
- Adult Intensive Care Unit, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - François Stéphan
- Adult Intensive Care Unit, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France.,Paris-Saclay University, School of Medicine, Paris, France
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Genty T, Cherel Q, Thès J, Bouteau A, Roman C, Stéphan F. Prone positioning during veno-venous or veno-arterial extracorporeal membrane oxygenation: feasibility and complications after cardiothoracic surgery. Crit Care 2022; 26:66. [PMID: 35313952 PMCID: PMC8936034 DOI: 10.1186/s13054-022-03944-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/08/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Thibaut Genty
- Cardiothoracic Intensive Care Unit, Service de Réanimation adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France.
| | - Quentin Cherel
- Cardiothoracic Intensive Care Unit, Service de Réanimation adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - Jacques Thès
- Cardiothoracic Intensive Care Unit, Service de Réanimation adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - Astrid Bouteau
- Cardiothoracic Intensive Care Unit, Service de Réanimation adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - Calypso Roman
- Cardiothoracic Intensive Care Unit, Service de Réanimation adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Service de Réanimation adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France.,School of Medicine, Paris-Saclay University, Kremlin-Bicêtre, France.,INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
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Genty T, Laverdure F, Peyrouset O, Rezaiguia-Delclaux S, Thès J, Stéphan F. Extubation Failure Prediction by Echography of the Diaphragm After Cardiothoracic Surgery: The EXPEDIA Study. Respir Care 2022; 67:308-315. [PMID: 34983832 PMCID: PMC9993501 DOI: 10.4187/respcare.09476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Successful extubation is difficult to predict. Ultrasound measurement of the diaphragm thickening fraction (DTF) might help predict weaning failure after cardiothoracic surgery. METHODS We assessed the predictive performance of diaphragm ultrasound in a derivation cohort of 50 prospectively included cardiothoracic surgery subjects ready for a weaning trial and in a validation cohort of 39 subjects ventilated for ≥ 48 h. DTF was assessed by ultrasound during pressure support ventilation (PSV) then during a T-piece spontaneous breathing trial (SBT). DTF was the percentage change in diaphragm thickness between expiration and inspiration and DTFmax, the higher DTF value of the 2 hemidiaphragms. DTFmax during SBT (static study) and the difference in DTFmax between PSV and SBT (dynamic study) were analyzed. RESULTS In the derivation cohort, DTFmax during SBT was 25.6 ± 17.3% in subjects with successful extubation and 65.2 ± 17.3% in those with weaning failure (difference 39.7 [95% CI 27.4-51.9], P < .01). During SBT, DTFmax ≥ 50% was associated with weaning failure (area under the receiver operating characteristic curve [AUC] 0.94 ± 0.05). In the dynamic study, a ≥ 40% DTFmax increase was associated with weaning failure (AUC 0.91 ± 0.06). In the validation cohort, DTFmax during SBT was 20.3 ± 17.1% in subjects with successful extubation and 82.0 ± 51.6% in those with weaning failure (difference 61.8 [95% CI 41.6-82.0], P < .01). During SBT, DTFmax ≥ 50% predicted weaning failure (AUC 0.99 ± 0.02). In the dynamic study, a ≥ 40% increase in DTFmax predicted weaning failure (AUC 0.81 ± 0.09). CONCLUSIONS Measuring DTFmax during SBT and the DTFmax change when switching from PSV to SBT may help predict weaning failure after cardiothoracic surgery. The study was registered on ANZCTR. CLINICAL TRIAL REGISTRATION NUMBER U1111-1180-1999.
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Affiliation(s)
- Thibaut Genty
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France.
| | - Florent Laverdure
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Olivier Peyrouset
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Saïda Rezaiguia-Delclaux
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Jacques Thès
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - François Stéphan
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France and University Paris Saclay Faculty of Medicine, Kremlin Bicêtre, France
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Vancappel A, Dansou Y, Godin O, Haffen E, Yrondi A, Stéphan F, Richieri R, Molière F, Horn M, Allauze E, Genty JB, Bouvard A, Dorey JM, Meyrel M, Camus V, Fond G, Péran B, Walter M, Anguill L, Scotto d'Apollonia C, Nguon AS, Fredembach B, Holtzmann J, Vilà E, Petrucci J, Rey, Etain B, Carminati M, Courtet P, Vaiva G, Llorca PM, Leboyer M, Aouizerate B, Bennabi D, El-Hage W. Cognitive impairments in treatment-resistant depression: Results from the French cohort of outpatients (FACE-DR). Journal of Affective Disorders Reports 2021. [DOI: 10.1016/j.jadr.2021.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Genty T, Wirth C, Humbert M, Fadel E, Stéphan F. Pulmonary Endarterectomy in Patients With Myeloproliferative Neoplasms. Chest 2021; 161:552-556. [PMID: 34537187 DOI: 10.1016/j.chest.2021.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 08/23/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Thibaut Genty
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Camille Wirth
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- University Paris-Saclay, Faculty of Medicine, Le Plessis-Robinson, France; INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Reference Center of Hôpital Bicêtre, Kremlin-Bicêtre, France
| | - Elie Fadel
- University Paris-Saclay, Faculty of Medicine, Le Plessis-Robinson, France; INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; University Paris-Saclay, Faculty of Medicine, Le Plessis-Robinson, France; INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Reference Center of Hôpital Bicêtre, Kremlin-Bicêtre, France.
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Amaru P, Delannoy B, Genty T, Desebbe O, Laverdure F, Rezaiguia-Delclaux S, Stéphan F. Effect of Recruitment Maneuvers and PEEP on Respiratory Failure After Cardiothoracic Surgery in Obese Subjects: A Randomized Controlled Trial. Respir Care 2021; 66:1306-1314. [PMID: 33975901 PMCID: PMC9994372 DOI: 10.4187/respcare.08607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obesity may increase the risk of respiratory failure after cardiothoracic surgery. A recruitment maneuver followed by PEEP might decrease the risk of respiratory failure in obese subjects. We hypothesized that the routine use after heart surgery of a recruitment maneuver followed by high or low PEEP level would decrease the frequency of respiratory failure in obese subjects. METHODS In a pragmatic, randomized controlled trial, we assigned obese subjects (ie, with body mass index [BMI] ≥ 30 kg/m2) in the immediate postoperative period of cardiothoracic surgery to either volume control ventilation with 5 cm H2O of PEEP (control group) or a recruitment maneuver followed by 5 or 10 cm H2O of PEEP in the intervention arms (RM5 and RM10 groups, respectively). The primary outcome was the proportion of subjects with postextubation respiratory failure, defined as the need for re-intubation, bi-level positive airway pressure, or high-flow nasal cannula within the first 48 h. RESULTS The study included 192 subjects: 65 in the control group (BMI 33.5 ± 3.2 kg/m2), 66 in the RM5 group (BMI 34.5 ± 3.2 kg/m2, and 61 in RM10 group (BMI 33.8 ± 4.8 kg/m2). Postextubation respiratory failure occurred in 14 subjects in the control group (21.5% [95% CI 13.3-35.3]), 21 subjects in the RM5 group (31.8% [95% CI 21.2-44.6]), and 9 subjects in the RM10 group (14.7% [95% CI 7.4-26.7]) (P = .07). The recruitment maneuver was stopped prematurely due to severe hypotension in 8 (12.1%) RM5 subjects and in 4 (6.6%) RM10 subjects (P = .28). There were no significant differences between the 3 groups for the frequencies of atelectasis, pneumonia, and death in the ICU. CONCLUSIONS The routine use after heart surgery of a recruitment maneuver followed by 5 or 10 cm H2O of PEEP did not decrease the frequency of respiratory failure in obese subjects. A recruitment maneuver followed by 5 cm H2O of PEEP is inappropriate.
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Affiliation(s)
- Priscilla Amaru
- Cardiothoracic ICU, Department of Anesthesiology and ICU, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | | | - Thibaut Genty
- Cardiothoracic ICU, Department of Anesthesiology and ICU, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | | | - Florent Laverdure
- Anesthesiology, Department of Anesthesiology and ICU, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | | | - François Stéphan
- Cardiothoracic ICU, Department of Anesthesiology and ICU, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
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Rezaiguia-Delclaux S, Stéphan F. In Response. Anesth Analg 2021; 132:e74. [PMID: 33857990 DOI: 10.1213/ane.0000000000005354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Saïda Rezaiguia-Delclaux
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Saclay, Paris, France,
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Rezaiguia-Delclaux S, Laverdure F, Genty T, Imbert A, Pilorge C, Amaru P, Sarfati C, Stéphan F. Neuromuscular Blockade Monitoring in Acute Respiratory Distress Syndrome: Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation. Anesth Analg 2021; 132:1051-1059. [PMID: 33002927 DOI: 10.1213/ane.0000000000005174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Whether train-of-four (TOF) monitoring is more effective than clinical monitoring to guide neuromuscular blockade (NMB) in patients with acute respiratory distress syndrome (ARDS) is unclear. We compared clinical monitoring alone or with TOF monitoring to guide atracurium dosage adjustment with respect to drug dose and respiratory parameters. METHODS From 2015 to 2016, we conducted a randomized controlled trial comparing clinical assessments every 2 hours with or without corrugator supercilii TOF monitoring every 4 hours in patients who developed ARDS (Pao2/Fio2 <150 mm Hg) in a cardiothoracic intensive care unit. The primary outcome was the cumulative atracurium dose (mg/kg/h). Secondary outcomes included respiratory parameters during the neuromuscular blockade. RESULTS A total of 38 patients in the clinical + TOF (C + TOF) group and 39 patients in the clinical (C) group were included in an intention-to-treat (ITT) analysis. The cumulative atracurium dose was higher in the C + TOF group (1.06 [0.75-1.30] vs 0.65 [0.60-0.89] mg/kg/h in the C group; P < .001) compared to C group, as well as the atracurium daily dose (C + TOF - C group mean difference = 0.256 mg/kg/h [95% confidence interval {CI}, 0.099-0.416], P = .026). Driving pressures during neuromuscular blocking agent (NMBA) administration did not differ between groups (P = .653). Intensive care unit (ICU) mortality was 22% in the C group and 27% in the C + TOF group (P = .786). Days on ventilation were 17 (8-26) in the C group and 16 (10-35) in the C + TOF group. CONCLUSIONS In patients with ARDS, adding TOF to clinical monitoring of neuromuscular blockade did not change ICU mortality or days on mechanical ventilation (MV) but did increase atracurium consumption when compared to clinical assessment alone. TOF monitoring may not be needed in all patients who receive neuromuscular blockade for ARDS.
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Affiliation(s)
| | | | | | | | | | | | - Céline Sarfati
- Physiotherapy Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
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Helou J, Korkomaz J, Stéphan F, Soutou B. Recherche de facteurs prédictifs d’efficacité et d’effets secondaires du laser CO2 fractionné. Ann Dermatol Venereol 2020. [DOI: 10.1016/j.annder.2020.09.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Stéphan F, Gutermann L, Djabarouti S, Fardini Y, Clerson P, Belmokhtar C, Hébert G. A new human fibrinogen concentrate (FIBRYGA®) In paediatric patients undergoing cardiac surgery: first real-world experience based on temporary authorization in France. J Cardiothorac Vasc Anesth 2020. [DOI: 10.1053/j.jvca.2020.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Stéphan F, Gutermann L, Pennetier M, Djabarouti S, Fardini Y, Clerson P, Belmokhtar C, Hébert G. Use of a new human fibrinogen concentrate (FIBRYGA®) In cardiac surgeries: first real-world experience in France based on temporary authorization. J Cardiothorac Vasc Anesth 2020. [DOI: 10.1053/j.jvca.2020.09.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Rézaiguia-Delclaux S, Haddad F, Pilorge C, Amsallem M, Fadel E, Stéphan F. Limitations of right ventricular annular parameters in the early postoperative period following pulmonary endarterectomy: an observational study. Interact Cardiovasc Thorac Surg 2020; 31:191-198. [PMID: 32577738 DOI: 10.1093/icvts/ivaa088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/11/2020] [Accepted: 04/19/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Echocardiographic right ventricular (RV) annular parameters are probably not as reliable to evaluate the surgical success in the postoperative period after pulmonary endarterectomy (PEA), whereas RV end-diastolic/left ventricular end-diastolic area ratio (RVEDA/LVEDA ratio) could be more useful. This study examined the relationship between RV annular parameters or RVEDA/LVEDA ratio and ideal cardiac index (ICI), before and after PEA. METHODS Among 80 patients who underwent PEA, the relationships between RVEDA/LVEDA ratio (21 patients), or tricuspid annular plane systolic excursion (32 patients), or systolic tricuspid annular velocity (55 patients) and ICI were modelled. RESULTS Forty-eight hours following PEA, mean pulmonary artery pressure decreased (26 ± 6 vs 46 ± 12 mmHg, P < 0.0001) and ICI improved (2.8 ± 0.8 vs 3.0 ± 0.9 l/min/m2, P = 0.02). In contrast to the moderate association between RV annular indices and ICI in the preoperative period, no significant relationship was found in the postoperative period (r = 0.54 and 0.17 for tricuspid annular plane systolic excursion and r = 0.46 and 0.16 for systolic tricuspid annular velocity, respectively). The RVEDA/LVEDA ratio significantly decreased postoperatively (0.97 ± 0.21 vs 1.19 ± 0.43, P = 0.002) and was correlated with ICI both in preoperative and postoperative periods (r = 0.57 and 0.57, respectively). There was a significant correlation between changes in RVEDA/LVEDA ratio and changes in total pulmonary resistance. CONCLUSIONS Improved ICI and RVEDA/LVEDA ratio reflected the surgical success of PEA and lowering of total pulmonary resistances. In contrast to the RV/left ventricular area ratio, annular RV indices associated poorly with postoperative ICI. Recognizing this limitation is important in minimizing the overdiagnosis of RV dysfunction after PEA.
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Affiliation(s)
| | - François Haddad
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Catherine Pilorge
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Myriam Amsallem
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Laverdure F, Delaporte A, Bouteau A, Genty T, Decailliot F, Stéphan F. Impact of initial respiratory compliance in ventilated patients with acute respiratory distress syndrome related to COVID-19. Crit Care 2020; 24:412. [PMID: 32646470 PMCID: PMC7347264 DOI: 10.1186/s13054-020-03133-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Florent Laverdure
- Department of Anesthesiology and Intensive Care, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France.
| | - Amélie Delaporte
- Department of Anesthesiology and Intensive Care, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Astrid Bouteau
- Department of Anesthesiology and Intensive Care, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Thibaut Genty
- Department of Anesthesiology and Intensive Care, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - François Decailliot
- Pediatric Intensive Care Unit, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - François Stéphan
- Department of Anesthesiology and Intensive Care, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
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Samalin L, Yrondi A, Charpeaud T, Genty JB, Blanc O, Sauvaget A, Stéphan F, Walter M, Bennabi D, Bulteau S, Haesebaert F, D'Amato T, Poulet E, Holtzmann J, Richieri RM, Attal J, Nieto I, El-Hage W, Bellivier F, Schmitt L, Lançon C, Bougerol T, Leboyer M, Aouizerate B, Haffen E, Courtet P, Llorca PM. Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode. J Affect Disord 2020; 264:318-323. [PMID: 32056767 DOI: 10.1016/j.jad.2020.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/20/2019] [Accepted: 01/03/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND ECT is the most effective treatment of major depressive episode (MDE) but remains a neglected treatment. The French Society for Biological Psychiatry and Neuropsychopharmacology aimed to determine whether prescribing practice of ECT followed guidelines recommendations. METHODS This multicenter, retrospective study included adult patients with major depressive disorder (MDD) or bipolar disorder (BD), who have been treated with ECT for MDE. Duration of MDE and number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests. RESULTS Seven hundred and forty-five individuals were included. The mean duration of MDE before ECT was 10.1 months and the mean number of lines of treatment before ECT was 3.4. It was significantly longer for MDD single episode than recurrent MDD and BD. The presence of first-line indications for using ECT was significantly associated to shorter duration of MDE (9.1 vs 13.1 months, p<0.001) and lower number of lines of treatment before ECT (3.3 vs 4.1, p<0.001). LIMITATIONS This is a retrospective study and not all facilities practicing ECT participated that could limit the extrapolation of the results. CONCLUSION Compared to guidelines, ECT was not used as first-line strategy in clinical practice. The presence of first-line indications seemed to reduce the delay before ECT initiation. The improvements of knowledge and access of ECT are needed to decrease the gap between guidelines and clinical practice.
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Affiliation(s)
- L Samalin
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand EA 7280, France.
| | - A Yrondi
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Service de Psychiatrie et de Psychologie Médicale de l'adulte, CHU de Toulouse, Hôpital Purpan, ToNIC Toulouse NeuroImaging Center, University of Toulouse, Inserm, UPS, Toulouse, France
| | - T Charpeaud
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand EA 7280, France
| | - J B Genty
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; University of Paris-Est, UMR_S955, UPEC, Créteil, France Inserm, U955, Equipe 15 Psychiatrie génétique, Créteil, France; AP-HP, Hôpital H. Mondor-A. Chenevier, Pôle de psychiatrie, Créteil, France
| | - O Blanc
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand EA 7280, France
| | - A Sauvaget
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; CHU Nantes, Movement - Interactions - Performance, MIP, EA 4334, INSERM-U1246 SPHERE University of Nantes and University of Tours, Nantes, France
| | - F Stéphan
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Service Hospitalo-Universitaire de Psychiatrie Générale et de Réhabilitation Psycho Sociale, EA 7479, CHRU de Brest, Hôpital de Bohars, Brest, France
| | - M Walter
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Service Hospitalo-Universitaire de Psychiatrie Générale et de Réhabilitation Psycho Sociale, EA 7479, CHRU de Brest, Hôpital de Bohars, Brest, France
| | - D Bennabi
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of Clinical Psychiatry, CIC-1431 INSERM, CHU de Besançon, EA481 Neurosciences, University Bourgogne Franche-Comté, Besançon, France
| | - S Bulteau
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; CHU Nantes, Movement - Interactions - Performance, MIP, EA 4334, INSERM-U1246 SPHERE University of Nantes and University of Tours, Nantes, France
| | - F Haesebaert
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Centre Hospitalier Le Vinatier, Inserm U1028, CNRS UMR5292, Lyon Neuroscience Research Center, PSY-R2 Team, University Lyon 1, Lyon, France
| | - T D'Amato
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Centre Hospitalier Le Vinatier, Inserm U1028, CNRS UMR5292, Lyon Neuroscience Research Center, PSY-R2 Team, University Lyon 1, Lyon, France
| | - E Poulet
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of Emergency Psychiatry, hospices civils de Lyon, Edouard-Herriot Hospital, Neuroscience Research Center, CNRS UMR5292, PSY-R2 Team, University Lyon, Lyon, France
| | - J Holtzmann
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; CHU Grenoble Alpes, Grenoble Institut Neurosciences, Inserm, U1216, University of Grenoble Alpes, Grenoble, France
| | - R M Richieri
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Pôle Psychiatrie, CHU La Conception, Marseille, France
| | - J Attal
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; University Department of Adult Psychiatry, La Colombiere Hospital, CHU Montpellier, University of Montpellier 1, Inserm, Montpellier 1061, France
| | - I Nieto
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences Tête et Cou, Inserm UMRS 1144, University Paris Diderot, Paris, France 16 UMR 1253, iBrain, University of Tours, Inserm, Tours, France
| | - W El-Hage
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of General and Academic Psychiatry, CH Charles Perrens, Bordeaux, Laboratory Nutrition and Integrative Neurobiology (UMR INRA 1286), University of Bordeaux, Bordeaux, France
| | - F Bellivier
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences Tête et Cou, Inserm UMRS 1144, University Paris Diderot, Paris, France 16 UMR 1253, iBrain, University of Tours, Inserm, Tours, France
| | - L Schmitt
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Service de Psychiatrie et de Psychologie Médicale de l'adulte, CHU de Toulouse, Hôpital Purpan, ToNIC Toulouse NeuroImaging Center, University of Toulouse, Inserm, UPS, Toulouse, France
| | - C Lançon
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Pôle Psychiatrie, CHU La Conception, Marseille, France
| | - T Bougerol
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; CHU Grenoble Alpes, Grenoble Institut Neurosciences, Inserm, U1216, University of Grenoble Alpes, Grenoble, France
| | - M Leboyer
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; University of Paris-Est, UMR_S955, UPEC, Créteil, France Inserm, U955, Equipe 15 Psychiatrie génétique, Créteil, France; AP-HP, Hôpital H. Mondor-A. Chenevier, Pôle de psychiatrie, Créteil, France
| | - B Aouizerate
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of General and Academic Psychiatry, CH Charles Perrens, Bordeaux, Laboratory Nutrition and Integrative Neurobiology (UMR INRA 1286), University of Bordeaux, Bordeaux, France
| | - E Haffen
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of Clinical Psychiatry, CIC-1431 INSERM, CHU de Besançon, EA481 Neurosciences, University Bourgogne Franche-Comté, Besançon, France
| | - P Courtet
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Inserm U1061, Montpellier University, Montpellier, France
| | - P M Llorca
- French Society for Biological Psychiatry and Neuropsychopharmacology, Saint Germain en Laye, France; Fondation Fondamental, Créteil, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand EA 7280, France
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Sarfati C, Moore A, Pilorge C, Amaru P, Mendialdua P, Rodet E, Stéphan F, Rezaiguia-Delclaux S. Efficacy of early passive tilting in minimizing ICU-acquired weakness: A randomized controlled trial. J Crit Care 2018; 46:37-43. [PMID: 29660670 DOI: 10.1016/j.jcrc.2018.03.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/30/2018] [Accepted: 03/30/2018] [Indexed: 10/17/2022]
Abstract
Purpose To investigate whether passive tilting added to a standardized rehabilitation therapy improved strength at Intensive Care Unit (ICU) discharge. Material and methods This single-center trial included patients admitted to an adult surgical ICU and ventilated for at least 3 days. Patients were randomized to daily standardized rehabilitation therapy alone or with tilting on a table for at least 1 h. The primary outcome was the Medical Research Council (MRC) sum score at ICU discharge. Muscular recovery was a secondary outcome. Results Of 145 included patients, 125 received mobilization, 65 in the Tilt group and 60 in the Control group. Total mobilization duration (median [25th–75th percentiles]) in the Tilt group was 1020 [580–1695] versus 1340 [536–2775] minutes in the Control group (p = 0.313). MRC sum scores at ICU discharge were not significantly different between groups (Tilt, 50 [45–56] versus 48 [45–54]; p = 0.555). However, the number of patients with weakness was higher in the Tilt group at baseline (Tilt: 60/65 versus 48/60, p = 0.045) and muscular recovery was better in the Tilt group (p = 0.004). Conclusions Passive tilting added to a standardized rehabilitation therapy did not improve muscle strength at ICU discharge in surgical patients even if a faster recovery with tilting is suggested.
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Affiliation(s)
- Céline Sarfati
- Physiotherapy Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
| | - Alex Moore
- Physiotherapy Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
| | - Catherine Pilorge
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
| | - Priscilla Amaru
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
| | - Paula Mendialdua
- Physiotherapy Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
| | - Emilie Rodet
- Physiotherapy Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France
| | - Saïda Rezaiguia-Delclaux
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis Robinson, Université Paris Sud, Paris, France.
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Stéphan F, Bérard L, Rézaiguia-Delclaux S, Amaru P. High-Flow Nasal Cannula Therapy Versus Intermittent Noninvasive Ventilation in Obese Subjects After Cardiothoracic Surgery. Respir Care 2017; 62:1193-1202. [PMID: 28807988 DOI: 10.4187/respcare.05473] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obese patients are considered at risk of respiratory failure after cardiothoracic surgery. High-flow nasal cannula has demonstrated its non-inferiority after cardiothoracic surgery compared to noninvasive ventilation (NIV), which is the recommended treatment in obese patients. We hypothesized that NIV was superior to high-flow nasal cannula for preventing or resolving acute respiratory failure after cardiothoracic surgery in this population. METHODS We performed a post hoc analysis of a randomized, controlled trial. Obese subjects were randomly assigned to receive NIV for at least 4 h/d (inspiratory pressure, 8 cm H2O; expiratory pressure, 4 cm H2O; FIO2 , 0.5) or high-flow nasal cannula delivered continuously (flow, 50 L/min, FIO2 0.5). RESULTS Treatment failure (defined as re-intubation, switch to the other treatment, or premature discontinuation) occurred in 21 of 136 (15.4%, 95% CI 9.8-22.6%) subjects with NIV compared to 18 of 135 (13.3%, 95% CI 8.1-20.3%) subjects with high-flow nasal cannula (P = .62). No significant differences were found for dyspnea and comfort scores. Skin breakdown was significantly more common with NIV after 24 h (9.2%, 95% CI 5.0-16.0 vs 1.6%, 95% CI 1.0-6.0; P = .01). No significant differences were found for ICU mortality (5.9% for subjects with NIV vs 2.2% for subjects with high-flow nasal cannula, P = .22) or for any of the other secondary outcomes. CONCLUSIONS Among obese cardiothoracic surgery subjects with or without respiratory failure, the use of continuous high-flow nasal cannula compared to intermittent NIV (8/4 cm H2O) did not result in a worse rate of treatment failure. Because high-flow nasal cannula presents some advantages, it may be used instead of NIV in obese patients after cardiothoracic surgery.
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Affiliation(s)
- François Stéphan
- Service de Réanimation adulte, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
| | - Laurence Bérard
- APHP, GH HUEP, Hôpital St Antoine, Plateforme de recherche Clinique de l'Est Parisien (URC-Est-CRC-Est), Paris, France
| | | | - Priscilla Amaru
- Service de Réanimation adulte, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Courteille B, Brunet J, Ouattara A, Stéphan F, Gérard JL, Lorne E, Fischer MO. Protective ventilation during cardiac surgery: More than tidal volume? Anaesth Crit Care Pain Med 2016; 36:133-134. [PMID: 27890851 DOI: 10.1016/j.accpm.2016.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/03/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Benoît Courteille
- Pôle réanimations anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Jennifer Brunet
- Pôle réanimations anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Alexandre Ouattara
- CHU de Bordeaux, Department of Anaesthesia and Critical Care II, place Amélie-Raba-Léon, 33000 Bordeaux, France; Univ. Bordeaux, Biology of cardiovascular disease, U1034, F-33600 Pessac, France; INSERM, Biology of cardiovascular disease, U1034, F-33600 Pessac, France
| | - François Stéphan
- Service de réanimation adulte, centre chirurgical Marie-Lannelongue, 92350 Le-Plessis-Robinson, France
| | - Jean-Louis Gérard
- Pôle réanimations anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Emmanuel Lorne
- Anesthesiology and Critical Care Department, Amiens University Medical Center, avenue René-Laennec, 80054 Amiens, France; Inserm U1088, Jules Verne University of Picardy, centre universitaire de recherche en santé (CURS), chemin du Thil, 80025 Amiens cedex, France
| | - Marc-Olivier Fischer
- Pôle réanimations anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, université de Caen-Normandie, esplanade de la paix, CS 14032, 14000 Caen, France.
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Rezaiguia-Delclaux S, Laverdure F, Kortchinsky T, Lemasle L, Imbert A, Stéphan F. Fiber optic bronchoscopy and remifentanil target-controlled infusion in critically ill patients with acute hypoxaemic respiratory failure: A descriptive study. Anaesth Crit Care Pain Med 2016; 36:273-277. [PMID: 27867133 DOI: 10.1016/j.accpm.2016.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 06/07/2016] [Accepted: 07/11/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Sedation optimizes patient comfort and ease of execution during fiber optic bronchoscopy (FOB). Our objective was to describe the safety and efficacy of remifentanil-TCI during FOB in non-intubated, hypoxaemic, thoracic surgery ICU patients. METHODS Consecutive spontaneously breathing adults requiring FOB after thoracic surgery were included if they had hypoxaemia (PaO2/FiO2<300mmHg or need for non-invasive ventilation [NIV]) and prior FOB failure under topical anaesthesia. The remifentanil initial target was chosen at 1ng/mL brain effect-site concentration (Cet), then titrated to 0.5ng/mL Cet increments according to patient comfort and coughing. Outcomes were patient-reported pain and discomfort (Visual Analogue Scale scores), ventilatory support intensification within 24hours after bronchoscopy, and ease of FOB execution. RESULTS Thirty-nine patients were included; all had a successful FOB. Their median PO2/FiO2 before starting FOB was 187±84mmHg and 24 patients received NIV. Median [interquartile range] pain scores were not different before and after FOB (1.0 [0.0-3.0] and 0.0 [0.0-2.0], respectively). Discomfort was reported as absent or minimal by 27 patients (69%; 95% confidence interval [95% CI], 54-81%) and as bothersome but tolerable by 12 patients (31%; 95% CI, 19-46%). Mean FiO2 returned to baseline within 2hours after FOB in 30 patients; the remaining 9 patients (23%; 95% CI, 13-38%) received ventilatory support intensification. Ease of execution was good or very good in 34 patients (87%; 95% CI, 73-94%), acceptable in 4 patients, and poor in 1 patient (persistent cough). CONCLUSION Sedation with remifentanil-TCI during FOB with prior failure under topical anaesthesia alone was effective and acceptably safe in non-intubated hypoxaemic thoracic surgery patients.
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Affiliation(s)
- Saïda Rezaiguia-Delclaux
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France.
| | - Florent Laverdure
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - Talna Kortchinsky
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - Léa Lemasle
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - Audrey Imbert
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
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Affiliation(s)
- R. Haber
- Department of Dermatology; Hotel Dieu de France University Hospital; Beirut Lebanon
- Faculty of Medicine; Saint Joseph University; Beirut Lebanon
| | - F. Stéphan
- Department of Dermatology; Hotel Dieu de France University Hospital; Beirut Lebanon
- Faculty of Medicine; Saint Joseph University; Beirut Lebanon
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Laverdure F, Louvain-Quintard V, Kortchinsky T, Rezaiguïa-Delclaux S, Imbert A, Stéphan F. PF4-heparin antibodies during ECMO: incidence, course, and outcomes. Intensive Care Med 2016; 42:1082-3. [PMID: 26903478 DOI: 10.1007/s00134-016-4262-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Florent Laverdure
- Cardiothoracic Intensive Care Unit, Service de Réanimation Adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - Virginie Louvain-Quintard
- Hemostasis Laboratory, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - Talna Kortchinsky
- Cardiothoracic Intensive Care Unit, Service de Réanimation Adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - Saïda Rezaiguïa-Delclaux
- Cardiothoracic Intensive Care Unit, Service de Réanimation Adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - Audrey Imbert
- Cardiothoracic Intensive Care Unit, Service de Réanimation Adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Service de Réanimation Adulte, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350, Le Plessis Robinson, France.
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Stéphan F, Zarrouki Y, Mougeot C, Imbert A, Kortchinsky T, Pilorge C, Rézaiguia-Delclaux S. Non-Ventilator ICU-Acquired Pneumonia After Cardiothoracic Surgery: Accuracy of Diagnostic Tools and Outcomes. Respir Care 2015; 61:324-32. [PMID: 26701366 DOI: 10.4187/respcare.04059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Non-ventilator ICU-acquired pneumonia after cardiothoracic surgery is challenging to diagnose, and little is known about its impact on patient outcomes. Here, our primary objective was to compare the sensitivity and specificity of cultures of 2 types of fiberoptic bronchoscopy (FOB) specimens: endotracheal aspirates (FOB-EA) and bronchoalveolar lavage fluid (FOB-BAL). The secondary objectives were to evaluate the sensitivity and specificity of spontaneous sputum cultures and of the modified Clinical Pulmonary Infection Score (CPIS) and to describe patient outcomes. METHODS We conducted a prospective observational study of consecutive cardiothoracic surgery subjects with suspected non-ventilator ICU-acquired pneumonia. Using FOB-BAL cultures ≥10(4) cfu/mL as the reference standard, we evaluated the accuracy of FOB-EA ≥10(5) cfu/mL and spontaneous sputum ≥10(7) cfu/mL. On the day of FOB, we determined the modified CPIS. Mortality and antibiotic treatments were recorded. RESULTS Of 105 subjects, 57 (54.3%) received a diagnosis of non-ventilator ICU-acquired pneumonia. FOB-EA cultures had 82% (95% CI 69-91%) sensitivity and 100% (95% CI 89-100%) specificity and were significantly less sensitive than FOB-BAL cultures (P < .004). Spontaneous sputum was obtained from one-third of subjects. Spontaneous sputum cultures had 82% (95% CI 56-95%) sensitivity and 94% (95% CI 68-100%) specificity and were non-significantly less sensitive than FOB-BAL (P = .061). A modified CPIS >6 had 42% (95% CI 29-56%) sensitivity and 87% (95% CI 74-95%) specificity for non-ventilator ICU-acquired pneumonia. Antibiotic therapy was stopped in all subjects without non-ventilator ICU-acquired pneumonia, after 1.6 ± 1.2 d, without deleterious effects. CONCLUSIONS The modified CPIS has low diagnostic accuracy for non-ventilator ICU-acquired pneumonia. FOB-EA cultures perform less well than do FOB-BAL cultures for diagnosing non-ventilator ICU-acquired pneumonia. Spontaneous sputum is valuable when FOB cannot be performed but could be obtained in only a minority of subjects. When cultures are negative, antibiotic discontinuation is safe.
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Affiliation(s)
| | | | - Christine Mougeot
- Bacteriology Laboratory, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Affiliation(s)
- François Stéphan
- Service de Réanimation Adulte, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Stéphan F, Barrucand B, Petit P, Rézaiguia-Delclaux S, Médard A, Delannoy B, Cosserant B, Flicoteaux G, Imbert A, Pilorge C, Bérard L. High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial. JAMA 2015; 313:2331-9. [PMID: 25980660 DOI: 10.1001/jama.2015.5213] [Citation(s) in RCA: 307] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Noninvasive ventilation delivered as bilevel positive airway pressure (BiPAP) is often used to avoid reintubation and improve outcomes of patients with hypoxemia after cardiothoracic surgery. High-flow nasal oxygen therapy is increasingly used to improve oxygenation because of its ease of implementation, tolerance, and clinical effectiveness. OBJECTIVE To determine whether high-flow nasal oxygen therapy was not inferior to BiPAP for preventing or resolving acute respiratory failure after cardiothoracic surgery. DESIGN AND SETTING Multicenter, randomized, noninferiority trial (BiPOP Study) conducted between June 15, 2011, and January 15, 2014, at 6 French intensive care units. PARTICIPANTS A total of 830 patients who had undergone cardiothoracic surgery, of which coronary artery bypass, valvular repair, and pulmonary thromboendarterectomy were the most common, were included when they developed acute respiratory failure (failure of a spontaneous breathing trial or successful breathing trial but failed extubation) or were deemed at risk for respiratory failure after extubation due to preexisting risk factors. INTERVENTIONS Patients were randomly assigned to receive high-flow nasal oxygen therapy delivered continuously through a nasal cannula (flow, 50 L/min; fraction of inspired oxygen [FiO2], 50%) (n = 414) or BiPAP delivered with a full-face mask for at least 4 hours per day (pressure support level, 8 cm H2O; positive end-expiratory pressure, 4 cm H2O; FiO2, 50%) (n = 416). MAIN OUTCOMES AND MEASURES The primary outcome was treatment failure, defined as reintubation, switch to the other study treatment, or premature treatment discontinuation (patient request or adverse effects, including gastric distention). Noninferiority of high-flow nasal oxygen therapy would be demonstrated if the lower boundary of the 95% CI were less than 9%. Secondary outcomes included mortality during intensive care unit stay, changes in respiratory variables, and respiratory complications. RESULTS High-flow nasal oxygen therapy was not inferior to BiPAP: the treatment failed in 87 of 414 patients with high-flow nasal oxygen therapy (21.0%) and 91 of 416 patients with BiPAP (21.9%) (absolute difference, 0.9%; 95% CI, -4.9% to 6.6%; P = .003). No significant differences were found for intensive care unit mortality (23 patients with BiPAP [5.5%] and 28 with high-flow nasal oxygen therapy [6.8%]; P = .66) (absolute difference, 1.2% [95% CI, -2.3% to 4.8%]. Skin breakdown was significantly more common with BiPAP after 24 hours (10% vs 3%; 95% CI, 7.3%-13.4% vs 1.8%-5.6%; P < .001). CONCLUSIONS AND RELEVANCE Among cardiothoracic surgery patients with or at risk for respiratory failure, the use of high-flow nasal oxygen therapy compared with intermittent BiPAP did not result in a worse rate of treatment failure. The findings support the use of high-flow nasal oxygen therapy in similar patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01458444.
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Affiliation(s)
- François Stéphan
- Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | - Benoit Barrucand
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire, Besançon, France
| | - Pascal Petit
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire, Besançon, France
| | - Saida Rézaiguia-Delclaux
- Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | - Anne Médard
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire, Clermont Ferrand, France
| | - Bertrand Delannoy
- Département d'Anesthésie-Réanimation Centre Hospitalier Universitaire, Lyon, France
| | - Bernard Cosserant
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire, Clermont Ferrand, France
| | - Guillaume Flicoteaux
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire, Besançon, France
| | - Audrey Imbert
- Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | - Catherine Pilorge
- Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | - Laurence Bérard
- Hôpital St Antoine, Plateforme de recherche Clinique de l'Est Parisien, Paris, France
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Hélou J, Maatouk I, Obeid G, Moutran R, Stéphan F, Tomb R. Fractional laser for vitiligo treated by 10,600 nm ablative fractional carbon dioxide laser followed by sun exposure. Lasers Surg Med 2014; 46:443-8. [PMID: 24889492 DOI: 10.1002/lsm.22260] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Vitiligo is an acquired disorder of the skin and mucous membranes. Many patients with vitiligo remain in the refractory state despite the availability of numerous potential treatments. To the best of our knowledge, only one trial considers ablative fractional CO2 laser in the treatment of vitiligo. OBJECTIVE To investigate the effects of fractional CO2 laser followed by systemic sun exposure on non-segmental vitiligo (NSV). METHODS Ten patients presenting refractory NSV were enrolled in this study. The patients underwent three sessions, one month apart, of fractional CO2 laser therapy on the affected areas of the skin (L-group). Five days after each laser treatment, patients were asked to expose themselves to the sun for 2 hours on a daily basis. Objective and subjective clinical assessments were performed at the beginning and at the end of the treatment. The L-group was then compared to a control group (C-group) that consisted of vitiligo lesions in the same patients but with sun exposure as the exclusive therapy. RESULTS Compared to the C-group, the L-group showed better improvement in both objective and subjective assessments. There were no noticeable adverse events in terms of scarring and Koebner phenomenon among others. CONCLUSIONS All patients treated with both, laser sessions and sun exposure, improved their chronic NSV lesions. Improvement was less significant in patients who exhibited vitiligo lesions over articular surfaces such as elbows and underarms. The best results were observed in vitiligo plaques located on the face, neck and legs. Consequently, fractional CO2 laser followed by sun exposure could be considered as an alternative modality for the treatment of refractory vitiligo, especially in sunny regions.
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Affiliation(s)
- J Hélou
- Department of Dermatology, Hôtel-Dieu de France, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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Camous J, Decrombecque T, Louvain-Quintard V, Doubine S, Dartevelle P, Stéphan F. Outcomes of patients with antiphospholipid syndrome after pulmonary endarterectomy. Eur J Cardiothorac Surg 2013; 46:116-20. [DOI: 10.1093/ejcts/ezt572] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Dudau D, Camous J, Marchand S, Pilorge C, Rézaiguia-Delclaux S, Libert JM, Fadel E, Stéphan F. Incidence of nosocomial pneumonia and risk of recurrence after antimicrobial therapy in critically ill lung and heart-lung transplant patients. Clin Transplant 2013; 28:27-36. [PMID: 24410732 DOI: 10.1111/ctr.12270] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 12/29/2022]
Abstract
Little is known about the resolution of symptoms of nosocomial pneumonia (NosoP) after lung and heart-lung transplantation. The aim of this study was to describe the clinical response to antimicrobial therapy in (ICU) patients with NosoP after lung or heart-lung transplantation. Between January 2008 and August 2010, 79 lung or heart-lung transplantations patients were prospectively studied. NosoPwas confirmed by quantitative cultures of bronchoalveolar lavage or endotracheal aspirates. Clinical variables, sequential organ failure assessment (SOFA) score, and radiologic score were recorded from start of therapy until day 9. Thirty-five patients (44%) experienced 64 episodes of NosoP in ICU. Fourteen patients (40%) had NosoP recurrence. Most frequently isolated organisms were Enterobacteriaceae (30%), Pseudomonas aeruginosa (25%), and Staphylococcus aureus (20%). Sequential organ failure assessment (SOFA) score improved significantly at day 6 and C-reactive protein level at day 9. SOFA and radiologic scores differed significantly between patients with and without NosoP recurrence at day 3 and 9. The ICU mortality rate did not differ between patients with and without NosoP recurrence, and free of NosoP (14.3%, 9.5%, 11.4%, respectively) (p = 0.91). Severities of illness and lung injury were the two major risk factors for NosoP recurrence. Occurrence of NosoP has no impact on ICU mortality.
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Affiliation(s)
- Daniela Dudau
- Surgical intensive care unit, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Trehel-Tursis V, Louvain-Quintard V, Zarrouki Y, Imbert A, Doubine S, Stéphan F. Clinical and biologic features of patients suspected or confirmed to have heparin-induced thrombocytopenia in a cardiothoracic surgical ICU. Chest 2013; 142:837-844. [PMID: 22406956 DOI: 10.1378/chest.11-3074] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The diagnosis of heparin-induced thrombocytopenia (HIT) is problematic in the surgical ICU, as there are multiple potential explanations for thrombocytopenia. We conducted a study to assess the incidence, clinical presentation, and outcome of HIT in a cardiothoracic surgical ICU. METHODS From January 2005 to December 2010, all patients with suspicion of HIT were prospectively identified, and data were collected retrospectively. Detection of anti-PF4/heparin antibodies and functional assays were systematically performed. RESULTS During the study period, 5,949 patients were admitted to the ICU (2,751 after cardiac surgery and 3,198 after thoracic surgery), of whom 101 were suspected to have HIT(1.7% [95% CI, 1.4%-2.0%]). Suspicion of HIT occurred at a median of 5 (4-9) days after ICU admission. Diagnosis was confirmed in 28 of 5,949 patients (0.47% [95% CI, 0.33%-0.68%]).Thrombosis was detected in 14 patients with HIT (50%) and in 12 patients without HIT (16%)( P 5 .0006). After receiver operating characteristic analysis (area under curve 5 0.78 0.06),a 4Ts score ≥ 5 had a sensitivity of 86% and a specificity of 70%. Course of platelet count was similar between the two groups. Six patients (21%) with HIT and 20 (27%) without died( P 5 .77). CONCLUSIONS Even with a prospective platelet monitoring protocol, suspicion for HIT arose in <2% of patients in a cardiothoracic ICU. Most were found to have other causes of thrombocytopenia,with HIT confirmed in 28 of 101 suspected cases (0.47% of all patients in the ICU). The 4Ts score may have value by identifying patients who should have laboratory testing performed.The mortality of patients with HIT was not different from other very ill thrombocytopenic patients in the ICU.
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Affiliation(s)
| | | | | | | | - Sylvie Doubine
- Hemostasis Laboratory, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Stéphan F. [Managing of excessive bleeding after cardiac surgery under cardiopulmonary bypass]. Transfus Clin Biol 2012; 19:159-64. [PMID: 23039953 DOI: 10.1016/j.tracli.2012.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 07/21/2012] [Indexed: 11/19/2022]
Abstract
The occurrence of abnormal bleeding in postoperative cardiac surgery performed under cardiopulmonary bypass is relatively common. If the option of reoperation is not retained, the initiation of medical treatment is inevitable. Next to the transfusion of blood products, other therapies were often used empirically and as "off-label". The place of each in a future regimen should be based on well-conducted clinical studies to determine the optimal risk/benefit ratio.
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Affiliation(s)
- F Stéphan
- Réanimation adulte, centre chirurgical Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis Robinson, France.
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Arnékian V, Camous J, Fattal S, Rézaiguia-Delclaux S, Nottin R, Stéphan F. Use of prothrombin complex concentrate for excessive bleeding after cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:382-9. [PMID: 22623627 DOI: 10.1093/icvts/ivs224] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Prothrombin complex concentrates (PCCs) are sometimes used as 'off label' for excessive bleeding after cardiopulmonary bypass (CPB). The main objective of this study was to retrospectively evaluate the clinical and biological efficacy of PCC in this setting. METHODS We reviewed the charts of all patients who had undergone cardiac surgery under CPB in our institution for 2 years. Patients treated for active bleeding with haemostatic therapy were identified. Chest tube blood loss was quantified postoperatively in the first 24 h. Coagulation parameters were recorded at intensive care unit admission and in the patient's first 24 h. Thromboembolic complications were also ascertained. RESULTS Seventy-seven patients out of the 677 studied (11.4%) were included: PCC was solely administered in 24 patients (group I), fresh frozen plasma in 26 (group II) and both in 27 (group III). The mean dose of PCC was 10.0 UI/kg ± 3.5 for group I vs 14.1 UI/kg ± 11.2 for group III (P = 0.09). Initial blood loss in the first hour was different between the three groups (P = 0.05): 224 ± 131 ml for group I, 369 ± 296 ml for group II and 434 ± 398 ml for group III. Only group I vs group III presented a significant difference (P = 0.02). Variations of blood loss over time were no different according to the treatment groups (P = 0.12). Reductions in blood loss expressed in percentage showed no difference between the three groups after 2 h: 54.5% (68.6-30.8) for group I; 45.0% (81.6-22.2) for group II; 57.6 (76.0-2.1) for group III; (P = 0.89). Re-exploration for bleeding involved 1 patient in group I (4%), 2 in group II (8%) and 10 in group III (37%) (P = 0.002). Except for fibrinogen, variations of prothrombin time, activated partial thromboplastin time and platelets with time were not different according to the treatment groups. Cerebral infarction occurred in one patient in group II. CONCLUSIONS Administration of low-dose of PCC significantly decreased postoperative bleeding after CPB.
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Affiliation(s)
- Vrigina Arnékian
- Cardiothoracic Intensive Care Unit, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Riviere S, Monconduit J, Zarka V, Massabie P, Boulet S, Dartevelle P, Stéphan F. Failure of noninvasive ventilation after lung surgery: a comprehensive analysis of incidence and possible risk factors. Eur J Cardiothorac Surg 2011; 39:769-76. [DOI: 10.1016/j.ejcts.2010.08.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 07/28/2010] [Accepted: 08/10/2010] [Indexed: 11/17/2022] Open
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Camous J, N’da A, Etienne-Julan M, Stéphan F. Anesthetic management of pregnant women with sickle cell disease — effect on postnatal sickling complications. Can J Anaesth 2008; 55:276-83. [DOI: 10.1007/bf03017204] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
AIM Central venous catheter (CVC) is often inserted during liver resection because a low central venous pressure (CVP) reduces blood loss and the procedure may be associated with circulatory impairment. The aim of the study was to evaluate the usefulness of a CVC besides the measurements of CVP, and whether peripheral venous pressure (PVP) measurement could be used reliably in place of CVP. METHODS We conducted an observational study during a 16-month period. Number of CVC inserted, expected surgical difficulties, and intraoperative complications which could lead to treatment involving a CVC were prospectively recorded and analysed. Measurements of CVP and PVP were simultaneously obtained at different times during surgery. Bias and limits of agreement with their 95% confidence interval (95% CI) were calculated. RESULTS Of the 101 patients included, 28 had expected surgical difficulties. Of the 75 CVCs inserted, only six (8%) were used for another purpose that CVP measurement in patients with expected surgical difficulties. A total of 124 measurements in 23 patients were recorded. Mean CVP was 4.8 +/- 2.9 mmHg and mean PVP was 6.9 +/- 3.1 mmHg (P<0.0001). The bias was -2.1 +/- 1.1 mmHg (95% CI: -2.3 to -1.9). When adjusted by the average bias of -2 mmHg, PVP predicted a CVP</=5 mmHg with a sensitivity and a specificity of 93% and 87%, respectively. CONCLUSION Routine insertion of a CVC should be discussed in patients without expected surgical difficulties. Thus, PVP monitoring may suffice to estimate CVP in uncomplicated cases.
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Affiliation(s)
- F Stéphan
- Service d'Anesthésie, Centre Hospitalo-Universitaire de Pointe-à-Pitre, France et Université des Antilles et de la Guyane, Pointe-à-Pitre Cedex, Guadeloupe, France.
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Balick-Weber CC, Nicolas P, Hedreville-Montout M, Blanchet P, Stéphan F. Respiratory and haemodynamic effects of volume-controlled vs pressure-controlled ventilation during laparoscopy: a cross-over study with echocardiographic assessment. Br J Anaesth 2007; 99:429-35. [PMID: 17626027 DOI: 10.1093/bja/aem166] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The effects of pressure-controlled (PC) ventilation on the ventilatory and haemodynamic parameters during laparoscopy procedures had not been carefully assessed. This prospective cross-over study was undertaken to compare how volume-controlled (VC) and PC modes could affect pulmonary mechanics, gas exchange, and cardiac function in patients undergoing laparoscopy. METHODS Twenty-one patients undergoing laparoscopic urological procedures had their lungs ventilated at the beginning with VC ventilation. PC ventilation was instituted at the end of the VC sequence. Ventilator settings were adjusted to keep tidal volume, respiratory rate, and Fi(o(2)) constant in every mode. A complete set of ventilatory, haemodynamic, and gas exchange parameters was obtained under VC after 40 min of pneumoperitoneum and 20 min after switching for PC. Transoesophageal echocardiography was performed in order to evaluate systolic and diastolic function of the heart. RESULTS When VC was switched to PC, peak airway pressure decreased [mean (sd) 32 (6) vs 27 (6) cm H(2)O; P < 0.0001], peak inspiratory flow increased [17 (3) vs 48 (8) litre min(-1); P < 0.0001), and dynamic compliance improved [+15 (8)%]. No difference was noted for static airway pressure, static compliance, and arterial oxygenation. No significant change could be demonstrated in the systolic [left ventricular end-systolic wall stress 66 (16) vs 63 (14) x 10(3) dyn cm(-2) m(-2)] or diastolic function [early diastolic velocity 10.3 (2.5) vs 10.5 (2.7) cm s(-1)]. CONCLUSIONS In this study, no short-term beneficial effect of PC ventilation could be demonstrated over conventional VC ventilation in patients with pneumoperitoneum.
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Stéphan F, Sax H, Wachsmuth M, Hoffmeyer P, Clergue F, Pittet D. Reduction of Urinary Tract Infection and Antibiotic Use after Surgery: A Controlled, Prospective, Before-After Intervention Study. Clin Infect Dis 2006; 42:1544-51. [PMID: 16652311 DOI: 10.1086/503837] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2005] [Accepted: 02/01/2006] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Urinary tract infection is the most frequent health care-associated complication. We hypothesized that the implementation of a multifaceted prevention strategy could decrease its incidence after surgery. METHODS In a controlled, prospective, before-after intervention trial with 1328 adult patients scheduled for orthopedic or abdominal surgery, nosocomial infection surveillance was conducted until hospital discharge. A multifaceted intervention including specifically tailored, locally developed guidelines for the prevention of urinary tract infection was implemented for orthopedic surgery patients, and abdominal surgery patients served as control subjects. Infectious and noninfectious complications, adherence to guidelines, and antibiotic use were monitored before and after the intervention and again 2 years later. RESULTS The incidence of urinary tract infection decreased from 10.4 to 3.9 episodes per 100 patients in the intervention group (incidence-density ratio, 0.41; 95% CI, 0.20-0.79; P=.004). Adherence to guidelines was 82.2%. Both the frequency and the duration of urinary catheterization decreased following the intervention. Recourse to antibiotic therapy after surgery dropped in the intervention group from 17.9 to 15.6 defined daily doses per 100 patient-days (P<.005) because of a reduced need for the treatment of urinary tract infection (P<.001). Follow-up after 2 years revealed a sustained impact of the strategy and a subsequent low use of antibiotics, consistent with stable adherence to guidelines (80.8%). CONCLUSIONS A multifaceted prevention strategy can dramatically decrease postoperative urinary tract infection and contribute to the reduction of the overall use of antibiotics after surgery.
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Affiliation(s)
- François Stéphan
- Division of Anesthesiology, Department of Anesthesiology, Pharmacology, and Surgical Intensive Care, University of Geneva Hospitals, Geneva, Switzerland
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Stéphan F, Mabrouk N, Decailliot F, Delclaux C, Legrand P. Ventilator-associated pneumonia leading to acute lung injury after trauma: importance of Haemophilus influenzae. Anesthesiology 2006; 104:235-41. [PMID: 16436840 DOI: 10.1097/00000542-200602000-00006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia is a clear risk factor for acute lung injury which has been poorly described in trauma patients. This prospective study was undertaken to estimate the incidence of such ventilator-associated pneumonia leading to acute lung injury, the risk factors, and the associated morbidity and mortality in a group of multiple trauma patients. METHODS Trauma patients who were mechanically ventilated and survived at least 24 h were included. Ventilator-associated pneumonia was confirmed by a bacterial culture of a blind protected telescoping catheter with at least 10 colony-forming units/ml of at least one pathogen. Episodes of acute lung injury were prospectively recorded. RESULTS Ventilator-associated pneumonia was documented in 78 patients of the 175 included (44%) and led to the development of ventilator-associated pneumonia acute lung injury in 18 patients (23%). The sole independent risk factor for ventilator-associated pneumonia leading to acute lung injury was the presence of Haemophilus influenzae (hazard ratio, 8.8; 95% confidence interval, 2.7-28.6). Eleven (61%) of the 18 patients with ventilator-associated pneumonia leading to acute lung injury had development of a ventilator-associated pneumonia recurrence, as compared with 20 (33%) of the 60 patients with ventilator-associated pneumonia alone (P = 0.03). Seven (39%) of the 18 trauma patients with ventilator-associated pneumonia leading to acute lung injury died, as compared with 9 (15%) of the 60 trauma patients with ventilator-associated pneumonia alone (P = 0.04). CONCLUSION Acute lung injury complicated the course of 15% of ventilator-associated pneumonia in trauma patients. H. influenzae seemed to be one of the most frequent bacteria involved and the sole risk factor identified. Occurrence of ventilator-associated pneumonia leading to acute lung injury modified the prognosis of trauma patients.
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Affiliation(s)
- François Stéphan
- Department of Anesthesiology-Critical Care Medicine and Ambulatory Surgery, Pointe-à-Pitre Hospital, University of Antilles-Guyane, 97159 Pointe-à-Pitre Cedex, France.
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Decailliot F, Streich B, Heurtematte Y, Duvaldestin P, Cherqui D, Stéphan F. Hemodynamic effects of portal triad clamping with and without pneumoperitoneum: an echocardiographic study. Anesth Analg 2005; 100:617-622. [PMID: 15728040 DOI: 10.1213/01.ane.0000144592.20499.12] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The decrease of cardiac index observed during portal triad clamping (PTC) with and without pneumoperitoneum has been studied only with right heart catheterization. To better understand this decrease of cardiac index, we investigated the balance between the adequacy of preload and the ability of the heart to pump against an increased afterload, by using transesophageal echocardiography. Ten patients with PTC performed during laparoscopy and 10 with PTC performed during laparotomy were studied. Five minutes after PTC, the stroke volume, the left ventricular (LV) fractional area change (FAC), and the LV end-systolic wall stress (LVESWS) were measured as the conventional hemodynamic variables. Regional wall motion abnormalities (RWMA) were also recorded. In the laparotomy group, LV end-diastolic area decreased, and LVESWS did not increase significantly. FAC remained stable, and one patient developed RWMA. In the laparoscopic group, LV end-diastolic area remained stable, and LVESWS increased. FAC decreased significantly, and five patients developed RWMA. A decrease in preload was the main important change in the laparotomy group, and in the laparoscopic group a decrease in LV function was demonstrated that was likely a consequence of decreased LV preload and increased LV afterload. However, these did not necessitate stopping the procedure or releasing PTC in these study patients without cardiac disease.
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Affiliation(s)
- François Decailliot
- *Service d'Anesthésie-Réanimation Chirurgicale and †Service de Chirurgie Digestive, Assistance Publique-Hôpitaux de Paris Hôpital Henri Mondor and Université Paris XII, Créteil, France
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Valade N, Decailliot F, Rébufat Y, Heurtematte Y, Duvaldestin P, Stéphan F. Thrombocytosis after trauma: incidence, aetiology, and clinical significance. Br J Anaesth 2004; 94:18-23. [PMID: 15486007 DOI: 10.1093/bja/aeh286] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Our aim was to assess the occurrence, aetiology, and clinical significance of a platelet count greater than 600 x 10(3)/mm(3) in trauma patients. METHODS All trauma patients admitted to the intensive care unit (ICU) during a 13-month period were prospectively studied. Platelet counts were performed daily. We recorded the patient's age, sex, nature of trauma, severity of illness scores, episodes of infections in the ICU, acute lung injury, bleeding, and thromboembolic events. Patients with thrombocytosis were also followed during their hospital stay and 1 month after hospital discharge. RESULTS A total of 176 patients were included. Thrombocytosis developed in 36 patients (20.4%) at a mean (sd) time of 14.0 (4.0) days and the platelet count normalized 35.0 (13.0) days after admission to the ICU. All patients with thrombocytosis had one or more possible predisposing conditions before the occurrence of thrombocytosis: nosocomial infection occurred in 30 patients (83%), acute lung injury in 17 (47%), bleeding in 27 (75%), and administration of cathecholamines in 24 (67%). Three venous thromboembolic complications occurred in the ICU (1.7%) and one during follow-up. Only one patient presented thrombocytosis at the time of diagnosis. Despite the fact that patients with thrombocytosis had a greater severity of illness, the ICU mortality was comparable among patients with and without thrombocytosis (8 vs 14%, P=0.34). CONCLUSIONS Reactive thrombocytosis is a common finding after severe trauma and was found to be associated with a better survival than predicted by severity of illness score. Unless additional risk factors are present, reactive thrombocytosis is not associated with an increased risk of thromboembolic events.
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Affiliation(s)
- N Valade
- Unité de Réanimation chirurgicale et traumatologique, Service d'Anesthésie-Réanimation, AP-HP Hôpital Henri Mondor, and Université Paris XII 94000, Créteil, France
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Stéphan F, Ghiglione S, Decailliot F, Yakhou L, Duvaldestin P, Legrand P. Effect of excessive environmental heat on core temperature in critically ill patients. An observational study during the 2003 European heat wave. Br J Anaesth 2004; 94:39-45. [PMID: 15486005 DOI: 10.1093/bja/aeh291] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The primary goal of this study was to investigate the relation between the core temperature of critically ill patients and hot ambient temperatures during a heat wave. The second goal was to evaluate the impact of such a heat wave on the number of microbiological tests ordered. METHODS During a heat wave, from August 3 to 22, 2003, we conducted an observational study in the surgical intensive care unit (ICU) of a French hospital that had no air-conditioning at the time. The core temperature of 18 critically ill patients and 36 health-care workers was measured with a non-contact, infrared tympanic membrane thermometer. The association between the core body temperature in infected and non-infected critically ill patients and the staff members, and the ambient temperature in the ICU was analysed using linear regression. The number of microbiological tests ordered was also recorded and compared with the same period in the previous year. RESULTS The equation of the regression line for infected critically ill patients was: core temperature=33.5+0.16 x ambient temperature (R(2)=0.53; P<0.0001). The regression line was steeper than that for the non-infected patients (0.077; P<0.0001). The slopes of the regression lines for non-infected and control patients were similar (P=0.20). More blood cultures were carried out during the heat wave than at the same period during the year 2002 (4.80 blood cultures per 1000 patient-days vs 2.47 per 1000 patient-days; P=0.0006). CONCLUSION During a sustained high ambient temperature, hyperthermia can occur in critically ill infected patients and to a lesser extent in non-infected patients and health-care workers. The number of blood cultures requested rises substantially, leading to increased costs. Installation of air-conditioning is therefore recommended.
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Affiliation(s)
- F Stéphan
- Réanimation chirurgicale et traumatologique, Service d'Anesthésie-Réanimation, AP-HP Hôpital Henri Mondor and Université Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex, France.
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Stéphan F. [Thrombocytopenia and intensive care unit mortality: a simple marker not to be neglected!]. ACTA ACUST UNITED AC 2004; 23:777-8. [PMID: 15345245 DOI: 10.1016/j.annfar.2004.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Zinc is an essential trace element for the human organism. It acts like cofactor for the metalloenzymes involved in many cellular processes. Its anti-inflammatory activity, which is the basis of therapeutic use, other than acrodermatitis enteropathica, is not well known: production of cytokines, antioxidant activity. Its toxicity is very low, but marked at high doses during chronic administration by the risk of hypocupremia. It is not teratogenic and can be given during pregnancy. Its absorption, through the duodenum, is inhibited by excessive phytate intake. Maximum concentration is reached after 2 to 3 hours. It is widely distributed in the organism, mainly in muscles and bone. Excretion is predominantly digestive. Its spectacular effect in acrodermatitis enteropathica, through compensation of genetically determined malabsorption was discovered in 1973. Its usefulness in acne is based on the anti-inflammatory action and was first described with zinc sulfate, then with better tolerated gluconate. Many controlled studies have shown an efficacy on inflammatory lesions. Doses varied from 30 to 150 mg of elemental zinc and studies against cyclines have shown that minocycline has a superior effect; but zinc might be an alternative treatment when cyclines are contraindicated. To date we don't have convincing data for its use in other indications (leishmaniosis, warts, cutaneous ulcers). Tolerance at usual doses (200 mg of zinc gluconate or 30 mg of elemental zinc) is good. Major side effects are abdominal with nausea, vomiting, but are fleeting and dose dependent.
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Affiliation(s)
- F Stéphan
- Service de Dermatologie, Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex, France
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Abstract
BACKGROUND Transmission of microorganisms from the hands of healthcare workers is the main source of cross-infection and can be prevented by hand-cleansing. The authors assessed the compliance rate with hand-cleansing practices in the postanesthesia care unit and investigated factors associated with noncompliance. METHODS Patient care activities, indications for and compliance of postanesthesia care unit staff with hand-cleansing, defined as either washing hands with soap and water or rubbing hands with alcohol, were monitored at the time of patient admission and during their stay. Multivariate analysis identified predictors of noncompliance with hand-cleansing on admission after adjustment for confounders. RESULTS A total of 3,143 patient care activities, including 1,091 opportunities for hand-cleansing at high or medium risk for cross-transmission, were recorded among 187 patients. The higher the workload, the higher the number of indications for hand-cleansing and the lower the compliance. Average compliance with hand-cleansing at postanesthesia care unit admission was 19.6%. Independent predictors for noncompliance included caring for patients older than 65 yr (odds ratio, 2.23; 95% confidence interval, 1.40-3.57) and those recovering from clean/clean-contaminated surgery (odds ratio, 2.27; 95% confidence interval, 1.11-4.76), as well as high intensity of patient care (odds ratio, 1.01 per patient care activity; 95% confidence interval, 1.0-1.02). Compliance with hand-cleansing for patients already admitted to the postanesthesia care unit was 12.5%. CONCLUSIONS Failure to cleanse hands during patient care is common in the postanesthesia care unit and is associated with identifiable factors. The close relation between the intensity of patient care and noncompliance argues that hand-cleansing should not be viewed as a problematic individual behavior only, and system change must be considered in prevention strategies.
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Affiliation(s)
- Didier Pittet
- Infection Control Program, Department of Internal Medicine, University of Geneva Hospitals, Switzerland.
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Ben Hamida C, Lauzet JY, Rézaiguia-Delclaux S, Duvoux C, Cherqui D, Duvaldestin P, Stéphan F. Effect of severe thrombocytopenia on patient outcome after liver transplantation. Intensive Care Med 2003; 29:756-62. [PMID: 12677370 DOI: 10.1007/s00134-003-1727-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2002] [Accepted: 02/20/2003] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective was to identify factors associated with thrombocytopenia and to assess to what extent thrombocytopenia increases bleeding complications in liver transplant patients. DESIGN Retrospective study. SETTING Surgical intensive care unit in a university hospital. PATIENTS One hundred and sixty-one patients admitted to the intensive care unit after liver transplantation. INTERVENTION None. MEASUREMENTS AND RESULTS Incidence of thrombocytopenia was defined as a platelet count of <50 x 10(9)/l for at least 3 consecutive days, associated events for thrombocytopenia or bleeding were identified by a Cox proportional hazard analysis, and blood product consumption was studied. Thrombocytopenia occurred in 104 patients (65%) with a mortality rate of 18% compared with 2% in non-thrombocytopenic patients (p=0.002). Independent associated events for thrombocytopenia were need of dialysis (hazard ratio [HR], 2.30; 95% confidence interval (95% CI), 1.10-4.80) and value of preoperative platelet count (HR, 1.06; 95% CI, 1.01-1.12 by 10(4) platelet decrease). The unique associated event identified for significant bleeding was sepsis (HR, 34.80; 95% CI, 1.47-153.40). Severe thrombocytopenia led to an excess of blood product consumption (red blood cells and platelets units) during ICU stay. CONCLUSION Thrombocytopenia of <50 x 10(9)/l for 3 days is frequent after liver transplantation and as such is not an important contributor to bleeding. However, thrombocytopenia does reflect the severity of the postoperative course.
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Affiliation(s)
- Chaker Ben Hamida
- Département d'Anesthésie-Réanimation chirurgicale, AP-HP Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex, France
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Stéphan F, Bah MS, Desterke C, Rézaiguia-Delclaux S, Foulet F, Duvaldestin P, Bretagne S. Molecular diversity and routes of colonization of Candida albicans in a surgical intensive care unit, as studied using microsatellite markers. Clin Infect Dis 2002; 35:1477-83. [PMID: 12471566 DOI: 10.1086/344648] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2002] [Accepted: 08/15/2002] [Indexed: 11/04/2022] Open
Abstract
To evaluate the colonization of Candida species and the importance of cross-contamination with Candida albicans, we prospectively screened clinical specimens obtained from surgical patients in the intensive care unit (ICU) who had a high risk of yeast colonization. Genotyping of C. albicans was performed using microsatellite markers. Thirty-six of 94 patients acquired nosocomial yeast colonization and/or infection. A total of 1126 specimens were cultured, 167 (15%) of which yielded yeasts. All 122 isolates of C. albicans recovered from the 30 C. albicans-positive patients were genotyped. Twenty-four different genotypes were identified. No genotype was systematically associated with a specific room or time. Isolates recovered from different body sites of patients at different times had identical genotypes. Acquisition of C. albicans in the surgical ICU seems to be mainly endogenous. Microsatellite markers should also be developed for typing non-albicans Candida species to learn whether their epidemiology differs from that of C. albicans.
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Affiliation(s)
- François Stéphan
- Service d'Anesthésie-Réanimation Chirurgicale, Hôpital Henri Mondor, and Université Paris XII, Créteil, France
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Rezaiguia-Delclaux S, Lefaucheur JP, Zakkouri M, Duvoux C, Duvaldestin P, Stéphan F. Severe acute polyneuropathy complicating orthotopic liver allograft failure. Transplantation 2002; 74:880-2. [PMID: 12364871 DOI: 10.1097/00007890-200209270-00024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neuromuscular dysfunction complicating orthotopic liver transplantation (OLT) has rarely been described. We report three cases of severe acute motor deficit after OLT in a context of graft dysfunction. METHOD From December 1999 to December 2000, the muscle strength of all patients who underwent OLT in our hospital was checked during their stay in the intensive care unit. Patients having a severe motor deficit underwent electrophysiological examination within 2 weeks after the onset of deficit. RESULTS Three patients developed acute quadriplegia concomitant with early allograft failure in a series of 30 patients. In these three patients, electrophysiological signs of sensorimotor axonal polyneuropathy were found. No sepsis was observed; hepatic failure, together with acute renal insufficiency in two cases, was the only risk factor identified for critical illness neuropathy. CONCLUSION The physicians who take charge of patients after OLT must be aware of the possible occurrence of severe polyneuropathy in case of early allograft dysfunction.
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Affiliation(s)
- Saïda Rezaiguia-Delclaux
- Service d'Anesthésie-Réanimation Chirurgicale, Centre Hospitalier Universitaire Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
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Stéphan F, Ayoub N, Klein-Tomb L, Tomb R. [Erythromelanosis follicularis faciei and colli]. Ann Dermatol Venereol 2002; 129:63-5. [PMID: 11937934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Erythromelanosis follicularis of the face and neck, originally described in Japan by Kitamura et al. in 1960, is characterized by a clinical set of three: well-demarcated erythema, hyperpigmentation and follicular papules. It affects the face and the neck generally on both sides. Since the original description, it has seldom been reported in the literature. CASE REPORTS This paper reports two patients with unilateral presentation. DISCUSSION Having discussed the various differential diagnoses all published cases were listed and analyzed. The prevalence of this disease appears higher than is shown by the limited number of cases reported in the literature. It deserves more recognition. Its nosologic and aetiologic frames still remain to be clarified.
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Affiliation(s)
- F Stéphan
- Service de Dermatologie, Hôtel-Dieu de France, BP 16-6830 Achrafié, Beyrouth, Liban
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