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Roger C, Julié-Bibi S, Fages M, Castelli C, Jeannes P, Saïssi G, Landais P, Lefrant JY, Muller L. [ICU patients and days of intensive care: A mathematical model optimizing the consequences of ICU unit function, intensive care and continual monitoring on incurred supplementary costs]. ACTA ACUST UNITED AC 2013; 32:742-8. [PMID: 24135731 DOI: 10.1016/j.annfar.2013.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 08/22/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION "Critical Care Units" are intended to admit patients with multiple organ failure. The severity of patients admitted is variable. The aim of the study was to estimate the number of days that an optimum care organization could release, and therefore the additional admissions that would have been allowed. Estimates of earnings related to the various supplements were carried out jointly. METHODS Reporting days associated or not with a resuscitation care during the year 2011 in an ICU of a university hospital (16 beds), optimized patient flow simulation, and computation of medical act inducing financial supplements. RESULTS Six hundred and fifty-seven patients (SAPS II from 0 to 110, 41% ventilated more than 48hours, mortality=26%) were admitted representing 5095days (occupancy rate=87%). Two hundred and twenty-two patients (34%) did not trigger supplement for resuscitation care for 415days in the unit. Four hundred and thirty-five patients have triggered this supplement representing 4680days, including 3035days with resuscitation care and 1645 (35% of days valued resuscitation, 32% of total days) without any. The entire year 2011 has generated earnings of 3,980,192€. Optimization of management would have allowed the admission of additional 235 to 295 patients and potential additional earnings from 524,735€ to 1,063,804€, depending on the occupancy rate chosen (80% or real 2011s) and the severity of discharged patients. CONCLUSION Optimization of the patients flow between "Critical Care", Intensive Care and Continuous Monitoring Units would increase the number of patients admitted in "Critical Care" Units without any financial loss related to supplements.
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Affiliation(s)
- C Roger
- Unité de réanimation chirurgicale, service des réanimations, division anesthésie réanimation douleur urgence, CHU de Nîmes, place du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France
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Roger C, Mari A, Bousquet PJ, Louart G, Casano F, Cuvillon A, Muller L, Zoric L, Saïssi G, Lefrant JY. Élargissement des plages horaires de visites dans une unité de réanimation : l’avis des proches. ACTA ACUST UNITED AC 2010; 29:431-5. [DOI: 10.1016/j.annfar.2010.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2009] [Accepted: 03/11/2010] [Indexed: 10/19/2022]
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Lefrant JY, Muller L, de La Coussaye JE, Benbabaali M, Lebris C, Zeitoun N, Mari C, Saïssi G, Ripart J, Eledjam JJ. Temperature measurement in intensive care patients: comparison of urinary bladder, oesophageal, rectal, axillary, and inguinal methods versus pulmonary artery core method. Intensive Care Med 2003; 29:414-8. [PMID: 12577157 DOI: 10.1007/s00134-002-1619-5] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.0] [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: 01/18/2002] [Accepted: 11/21/2002] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Comparisons of urinary bladder, oesophageal, rectal, axillary, and inguinal temperatures versus pulmonary artery temperature. DESIGN Prospective cohort study. SETTING Intensive Care Unit of a University-Hospital. PATIENTS Forty-two intensive care patients requiring a pulmonary artery catheter (PAC). INTERVENTION Patients requiring PAC and without oesophageal, urinary bladder, and/or rectal disease or recent surgery were included in the study. Temperature was simultaneously monitored with PAC, urinary, oesophageal, and rectal electronic thermometers and with axillary and inguinal gallium-in-glass thermometers. Comparisons used a Bland and Altman method. MEASUREMENTS AND MAIN RESULTS The pulmonary arterial temperature ranged from 33.7 degrees C to 40.2 degrees C. Urinary bladder temperature was assessed in the last 22 patients. A total of 529 temperature measurement comparisons were carried out (252 comparisons of esophageal, rectal, inguinal, axillary, and pulmonary artery temperature measurements in the first 20 patients, and 277 comparisons with overall methods in the last patients). Nine to 18 temperature measurement comparisons were carried out per patient (median = 13). The mean differences between pulmonary artery temperatures and those of the different methods studied were: oesophageal (0.11+/-0.30 degrees C), rectal (-0.07+/-0.40 degrees C), axillary (0.27+/-0.45 degrees C), inguinal (0.17+/-0.48 degrees C), urinary bladder (-0.21+/-0.20 degrees C). CONCLUSION In critically ill patients, urinary bladder and oesophageal electronic thermometers are more reliable than the electronic rectal thermometer which is better than inguinal and axillary gallium-in-glass thermometers to measure core temperature.
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Affiliation(s)
- J-Y Lefrant
- Fédération Anesthésie-Douleur-Urgences-Réanimation, Centre Hospitalier Universitaire de Nîmes, 5 rue Hoche, 30029 Nîmes, France.
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Lefrant JY, Ripart J, de La Coussaye JE, Muller L, Vialles N, Fabbro-Peray P, Saïssi G, Eledjam JJ. [Pulmonary artery catheterization in the intensive care unit: at what time?]. Ann Fr Anesth Reanim 2001; 20:337-41. [PMID: 11392243 DOI: 10.1016/s0750-7658(01)00385-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Recording the time at which the insertion of a pulmonary artery catheter was decided. STUDY DESIGN Prospective and descriptive study. PATIENTS Critically ill patients in an university hospital. METHODS The times at which the insertion of a PAC was decided were recorded. For each pulmonary artery catheterization, immediate complications were recorded (arterial puncture, pneumothorax, ventricular arrhythmia, hard and failed pulmonary artery catheterization). RESULTS One hundred and forty-nine patients were included (99 males, age = 63 +/- 15 year, body mass index = 25 +/- 6 kg.m-2, median Apache II score = 16). One hundred and sixty-five PAC insertions were decided (16 patients requiring two PACs). Nine arterial punctures, two pneumothoraces, 42 ventricular arrhythmias, 32 hard and eight failed pulmonary artery catheterizations occurred. Thirty-four PAC insertions were decided between 9 and 10 am whereas = 3 PAC insertions per hour were decided between 1 and 9 am. CONCLUSION The rate of decision of PAC insertion are decreased during the second half of the night (1 to 9 AM).
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Affiliation(s)
- J Y Lefrant
- Fédération d'anesthésie-douleur-urgence-réanimation, CHU Nîmes, 5, rue Hoche, 30029 Nîmes, France.
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Lefrant JY, Muller L, Bruelle P, Pandolfi JL, L'Hermite J, Peray P, Saïssi G, de La Coussaye JE, Eledjam JJ. Insertion time of the pulmonary artery catheter in critically ill patients. Crit Care Med 2000; 28:355-9. [PMID: 10708166 DOI: 10.1097/00003246-200002000-00011] [Citation(s) in RCA: 33] [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: 11/25/2022]
Abstract
OBJECTIVES Measurement of the time elapsed from the decision to use a pulmonary artery catheter to the onset of the adapted treatment. DESIGN Prospective study. SETTING Critical care unit of a university hospital. PATIENTS A total of 104 critically ill patients. INTERVENTIONS The time elapsed from the decision to use a pulmonary artery catheter to the onset of the adapted treatment. Five time intervals (availability, preparation, catheterization, data collection, and therapeutic intervals) were individualized according to the times of decision of pulmonary artery catheter insertion, operator's hand washing, venipuncture, postoperative dressing, data collection, and the effective onset of subsequent therapy. MEASUREMENTS AND MAIN RESULTS Among 120 used pulmonary artery catheters, seven could not be inserted. The time to use the pulmonary artery catheter was never shorter than 45 mins (median value = 120 mins). For availability, preparation, catheterization, data collection, and therapeutic intervals, the median values were 30, 20, 20, 20, and 10 mins, respectively. The availability and data collection intervals were shortened during the night period and the fourth quarter of the study, respectively. CONCLUSIONS The pulmonary artery catheter use is time consuming. However, the availability and data collection intervals could be shortened.
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Affiliation(s)
- J Y Lefrant
- Fédération d'Anesthésie Douleur Urgences Réanimation, Centre Hospitalier Universitaire de Nîmes, France
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Lefrant JY, Cuvillon P, Bénézet JF, Dauzat M, Peray P, Saïssi G, de La Coussaye JE, Eledjam JJ. Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study. Anesthesiology 1998; 88:1195-201. [PMID: 9605678 DOI: 10.1097/00000542-199805000-00009] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.9] [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: 02/07/2023]
Abstract
BACKGROUND Catheterization of the subclavian vein may lead to severe complications. The current randomized study compared a technique of pulsed Doppler ultrasonography guidance and the standard method for subclavian vein catheterization. METHODS Standard and Doppler ultrasonography guidance methods were performed by the same physician in 286 patients, 143 in each group. Primary end points were immediate complications (arterial puncture, pneumothorax, wrong position of catheter tip), failures, the number of subclavian vein catheterizations with immediate complication or failure, the number of skin punctures per catheterization, and the time to placement of the guide wire. The secondary end points were the determination of predicting factors of successful cannulation in each group. RESULTS Both groups were similar according to morphologic parameters of the patients. A greater number of subclavian vein catheterizations were performed on the right side using Doppler guidance (105 vs. 73, P < 0.01). Doppler guidance decreased complications (5.6% vs. 16.8%, P < 0.01), largely because of a smaller number of catheters for which the tip was defined to be in incorrect position (0.7% vs. 7.7%, P < 0.01). The time to catheterization was longer with Doppler guidance (300 vs. 27 s, P < 0.001). Failures, catheterizations of the subclavian vein with immediate complications or failure, and the total number of skin punctures per catheterization were similar in both groups. Using Doppler guidance, the presence of a good Doppler signal (124 of 143) was predictive of successful catheterization (123 successful cannulations, P < 0.001). CONCLUSIONS Doppler guidance reduces the incidence of inappropriately positioned subclavian catheters.
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Affiliation(s)
- J Y Lefrant
- Department of Anesthesiology and Critical Care, University-Hospital of Nîmes, France
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Lefrant JY, Bruelle P, Aya AG, Saïssi G, Dauzat M, de La Coussaye JE, Eledjam JJ. Training is required to improve the reliability of esophageal Doppler to measure cardiac output in critically ill patients. Intensive Care Med 1998; 24:347-52. [PMID: 9609413 DOI: 10.1007/s001340050578] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.5] [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: 02/07/2023]
Abstract
OBJECTIVES Assessment of and effect of training on reliability of esophageal Doppler (ED) versus thermodilution (TD) for cardiac output (CO) measurement. DESIGN Prospective study. SETTING Intensive care unit of a university hospital. PATIENTS 64 consecutive critically ill patients requiring a pulmonary artery catheter, sedation, and mechanical ventilation. INTERVENTIONS Esophageal Doppler CO measurements were performed by the same operator, whereas TD CO measurements were carried out by other independent operators. A training period involving the first 12 patients made the operator self-confident. In the remaining patients, the reliability of ED was assessed (evaluation period), using correlation coefficients and the Bland and Altman diagram. Between training and evaluation periods, correlation coefficients, biases, and limits of agreement were compared. MEASUREMENTS AND RESULTS During training and evaluation periods, 107 and 320 CO measurements were performed in 11 out of 12 patients and in 49 out of 52 patients, respectively. Continuous CO monitoring was achieved in 6 out of 11 patients and in 38 out of 49 patients during training and evaluation periods, respectively. Between the two periods, correlation coefficients increased from 0.53 to 0.89 (p < 0.001), bias decreased from 1.2 to 0.1 l x min(-1) (p < 0.001), and limits of agreement decreased from 3.2 to 2.2 l x min(-1) (p < 0.001). CONCLUSION A period of training involving no more than 12 patients is probably required to ensure reliability of CO measurement by ED.
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Affiliation(s)
- J Y Lefrant
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nîmes, France
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Lefrant JY, Bruelle P, Ripart J, Ibanez F, Aya G, Peray P, Saïssi G, de La Coussaye JE, Eledjam JJ. Cardiac output measurement in critically ill patients: comparison of continuous and conventional thermodilution techniques. Can J Anaesth 1995; 42:972-6. [PMID: 8590506 DOI: 10.1007/bf03011067] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [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: 01/31/2023] Open
Abstract
The purpose of the study was to compare cardiac output (CO) measurement by continuous (CTD) with that by conventional thermodilution (TD) in critically ill patients. In 19 of 20 critically ill patients requiring a pulmonary artery catheterism, 105 paired CO measurements were performed by both CTD and TD. Regression analysis showed that: CTD CO = 1.18 TD CO - 0.47. Correlation coefficient was 0.96. Bias and limit of agreement were -0.8 and 2.4 L.min-1, respectively. When a Bland and Altman diagram was constructed according to cardiac index ranges, biases were -0.2 and -0.3 and -0.8 L.min-1.m-2 and limits of agreement were 0.3, 0.7 and 1.6 L.min-1.m-2 for low (< 2.5 L.min-1.m-2), normal (between 2.5 and 4.5 L.min-1.m-2) and high (> 4.5 L.min-1.m-2) cardiac indexes, respectively. It is concluded that CTD, compared with TD, is a reliable method of measuring CO, especially when cardiac index is < or = 4.5 L.min-1.m-2.
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Affiliation(s)
- J Y Lefrant
- Département d'Anesthésie-Réanimation et de l'Urgence, CHU Nîmes, France
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de La Coussaye JE, Eledjam JJ, Bassoul B, Bruelle P, Lefrant JY, Peray PA, Saïssi G, Desch G, Sassine A. Receptor mechanisms for clonidine reversal of bupivacaine-induced impairment of ventricular conduction in pentobarbital-anesthetized dogs. Anesth Analg 1994; 78:624-37. [PMID: 7907846 DOI: 10.1213/00000539-199404000-00003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [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: 01/27/2023]
Abstract
Possible mechanisms of the ability of clonidine to correct bupivacaine-induced ventricular electrophysiologic impairment were evaluated in an electrophysiologic model on closed-chest dogs. Nine groups (n = 6) of pentobarbital-anesthetized dogs were given atropine, 0.2 mg/kg intravenously (i.v.), and bupivacaine, 4 mg/kg i.v., over a 10-s period. Group 1 was then given only saline solution. Group 2 was given clonidine, 0.01 mg/kg i.v., over a 1-min period. Group 3 was given clonidine followed by i.v. administration of yohimbine, 1 mg/kg, an alpha 2-antagonist. Group 4 was given carbachol, 1 mg/kg i.v., a long-lasting cholinergic agonist, over a 1-min period. Group 5 was given electrical stimulation of the left vagus nerve. Group 6 was given physostigmine, 0.1 mg/kg i.v., known to inhibit cholinesterase degradation, 5 min before bupivacaine administration, and Group 7 received a combination of physostigmine pretreatment and electrical vagal stimulation. Group 8 was given physostigmine, 0.1 mg/kg i.v., and pancuronium bromide, 1 mg/kg i.v., known to inhibit nicotinic receptors, 5 min before bupivacaine administration. Then electrical stimulation of the left vagus nerve was performed. Group 9 was given nicotine, 0.1 mg/kg i.v., 1 min after bupivacaine injection over 1 min. Bupivacaine induced bradycardia, markedly increased the His-Purkinje conduction time (HV interval) and QRS duration. Bupivacaine decreased the peak of first derivative of left ventricle pressure (LVdP/dtmax) and increased left ventricular end-diastolic pressure (LVEDP). Clonidine improved QRS duration and HV interval. Yohimbine did not modify the effects of clonidine. QRS duration and HV interval were significantly improved in Groups 4-7. In Group 8, pancuronium pretreatment inhibited the beneficial effects of the combination of physostigmine pretreatment and electrical vagal stimulation. In contrast, in Group 9, like clonidine, nicotine improved QRS duration and HV interval. Three other groups of anesthetized dogs (n = 6) were then studied. All dogs were given hexamethonium, 10 mg/kg i.v. Then, Group 10 was given only saline solution; Group 11 was given bupivacaine, 4 mg/kg, and Group 12 was given bupivacaine and nicotine as in Group 9. In Group 11, bupivacaine induced its usual alterations. In contrast, nicotine did not modify the cardiotoxic profile of bupivacaine after hexamethonium pretreatment. We conclude that the beneficial effect of clonidine on the variables of ventricular conduction altered by bupivacaine 1) is not mediated by central alpha 2-activation, 2) is mediated by the activation of parasympathetic pathways, and 3) is indirect and not mediated by acetylcholine release but is mediated by the activation of parasympathetic ganglionic nicotinic receptors.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- J E de La Coussaye
- Laboratory of Cardiovascular Physiology, Medical School of Montpellier-Nîmes, France
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Viel E, Lefrant JY, Saïssi G, Eledjam JJ. [Role of analgesia for sedation in intensive care medicine]. Cah Anesthesiol 1994; 42:797-807. [PMID: 7767733] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Giving a definition of analgesia in ICU needs to answer several questions: Why sedation? Which drugs can we use? How can we deal with sedation? (monitoring, continuous administration, weaning...)? Two different types of sedation must be considered: treatment-sedation (status epilepticus, tetanus, intracranial hypertension...) and comfort-sedation in anxious and/or restless and/or painful patients and in those necessitating mechanical ventilation. Analgesic consumptions vary widely with diseases and their outcome, background diseases and ICU environment. Several studies have shown that pain and analgesia are frequently neglected in ICU. The authors review the different drugs in use, with their advantages and drawbacks. A particular place is reserved to regional techniques, often underused in ICU. Indications are then fully discussed, according to several specific pathological conditions. Monitoring and weaning of sedation are also discussed at the end of the review.
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Affiliation(s)
- E Viel
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire, Nîmes
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Viel EJ, de La Coussaye JE, Bruelle P, Saïssi G, Bassoul BP, Eledjam JJ. Epidural anesthesia: a pitfall due to the technique of the loss of resistance to air. Reg Anesth 1991; 16:117-9. [PMID: 2043527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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