Model for predicting short-term mortality of severe sepsis

International audienceABSTRACT: INTRODUCTION: To establish a prognostic model for predicting 14-day mortality in ICU patients with severe sepsis overall and according to place of infection acquisition and to sepsis episode number. METHODS: In this prospective multicentre observational study on a multicentre database (OUTCOMEREA) including data from 12 ICUs, 2268 patients with 2737 episodes of severe sepsis were randomly divided into a training cohort (n=1458) and a validation cohort (n=810). Up to four consecutive severe sepsis episodes per patient occurring within the first 28 ICU days were included. We developed a prognostic model for predicting death within 14 days after each episode, based on patient data available at sepsis onset. RESULTS: Independent predictors of death were logistic organ dysfunction (OR, 1.22 per point, p<10-4), septic shock (OR, 1.40; p=0.01), rank of severe sepsis episode (1 reference, 2: OR, 1.26; p=0.10 [greater than or equal to]3: OR, 2.64 ;10-3), multiple sources of infection (OR; 1.45, p=0.03), simplified acute physiology score II (OR, 1.02 per point; p<10-4), McCabe score ([greater than or equal to]2)(OR, 1.96; p<10-4), and number of chronic co-morbidities (1: OR, 1.75; p=10-3, [greater than or equal to]2: OR, 2.24, p= 10-3). Validity of the model was good in whole cohorts (AUC-ROC, 0.76; 95%CI [0.74; 0.79] and HL Chi-square: 15.3 (p=0.06) for all episodes pooled). CONCLUSIONS: In ICU patients, a prognostic model based on a few easily obtained variables is effective in predicting death within 14 days after the first to fourth episode of severe sepsis complicating community-, hospital-, or ICU-acquired infection

Impact of ureido/carboxypenicillin resistance on the prognosis of ventilator-associated pneumonia due to Pseudomonas aeruginosa

International audienceINTRODUCTION: Although Pseudomonas aeruginosa is a leading pathogen responsible for ventilator-associated pneumonia (VAP), the excess in mortality associated with multi-resistance in patients with P. aeruginosa VAP (PA-VAP), taking into account confounders such as treatment adequacy and prior length of stay in the ICU, has not yet been adequately estimated. METHODS: A total of 223 episodes of PA-VAP recorded into the Outcomerea database were evaluated. Patients with ureido/carboxy-resistant P. aeruginosa (PRPA) were compared with those with ureido/carboxy-sensitive P. aeruginosa (PSPA) after matching on duration of ICU stay at VAP onset and adjustment for confounders. RESULTS: Factors associated with onset of PRPA-VAP were as follows: admission to the ICU with septic shock, broad-spectrum antimicrobials at admission, prior use of ureido/carboxypenicillin, and colonization with PRPA before infection. Adequate antimicrobial therapy was more often delayed in the PRPA group. The crude ICU mortality rate and the hospital mortality rate were not different between the PRPA and the PSPA groups. In multivariate analysis, after controlling for time in the ICU before VAP diagnosis, neither ICU death (odds ratio (OR) = 0.73; 95% confidence interval (CI): 0.32 to 1.69; P = 0.46) nor hospital death (OR = 0.87; 95% CI: 0.38 to 1.99; P = 0.74) were increased in the presence of PRPA infection. This result remained unchanged in the subgroup of 87 patients who received adequate antimicrobial treatment on the day of VAP diagnosis. CONCLUSIONS: After adjustment, and despite the more frequent delay in the initiation of an adequate antimicrobial therapy in these patients, resistance to ureido/carboxypenicillin was not associated with ICU or hospital death in patients with PA-VAP

Reliability of diagnostic coding in intensive care patients

International audienceABSTRACT: INTRODUCTION: Administrative coding of medical diagnoses in intensive care unit (ICU) patients is mandatory in order to create databases for use in epidemiological and economic studies. We assessed the reliability of coding between different ICU physicians. METHOD: One hundred medical records selected randomly from 29,393 cases collected between 1998 and 2004 in the French multicenter Outcomerea ICU database were studied. Each record was sent to two senior physicians from independent ICUs who recoded the diagnoses using the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision (ICD-10) after being trained according to guidelines developed by two French national intensive care medicine societies: the French Society of Intensive Care Medicine (SRLF) and the French Society of Anesthesiology and Intensive Care Medicine (SFAR). These codes were then compared with the original codes, which had been selected by the physician treating the patient. A specific comparison was done for the diagnoses of septicemia and shock (codes derived from A41 and R57, respectively). RESULTS: The ICU physicians coded an average of 4.6 +/- 3.0 (range 1 to 32) diagnoses per patient, with little agreement between the three coders. The primary diagnosis was matched by both external coders in 34% (95% confidence interval (CI) 25% to 43%) of cases, by only one in 35% (95% CI 26% to 44%) of cases, and by neither in 31% (95% CI 22% to 40%) of cases. Only 18% (95% CI 16% to 20%) of all codes were selected by all three coders. Similar results were obtained for the diagnoses of septicemia and/or shock. CONCLUSION: In a multicenter database designed primarily for epidemiological and cohort studies in ICU patients, the coding of medical diagnoses varied between different observers. This could limit the interpretation and validity of research and epidemiological programs using diagnoses as inclusion criteria

Prélèvement d'organes chez les patients en état de mort encéphaliques après un arrêt cardiaque récupéré

L'objectif est d'identifier les facteurs prédictifs de survenue de mort encéphalique chez les patients victimes d arrêt cardio-circulatoire survenu en milieu extra-hospitalier et évaluer le pronostic des organes solides prélevés chez ces patients. La pénurie de greffons en matière de dons d organes doit conduire à un dépistage approprié des donneurs potentiels. Les patients en état de mort encéphalique secondaire à un arrêt cardio-circulatoire réanimés avec succès sont des donneurs potentiels d organes à condition que ces derniers ne présentent pas de souffrance majeure suite à l arrêt cardio-circulatoire et au syndrome d ischémie reperfusion qui le suit. Par conséquence, le diagnostic de mort encéphalique et l évaluation de la qualité des organes solides dans cette population de donneurs méritent beaucoup d attention. Des patients victimes d arrêt cardio-circulatoire et réanimés avec succès ont été inclus prospectivement sur une période de sept ans. Nous avons cherché des facteurs prédictifs de survenue de mort encéphalique et nous avons comparé la survie des organes prélevés chez ces patients avec ceux prélevés chez les victimes d accidents vasculaires cérébraux ou de traumas crâniens. Résultats : 246 patients ont été inclus sur 7 ans. Aucun facteur prédictif de survenue de mort encéphalique n a été trouvé. 40 patients (16%) ont rempli les critères de mort encéphalique après une médiane de séjour de 2,5 jours (quartiles 2,0 et 4,2).19 d entre eux (50%) ont donné 52 organes solides (29 reins, 14 foies, 7 cœurs et 2 poumons). Le pronostic de survie de greffons (reins et foies) n était pas différent de ceux prélevés chez des patients en état de mort encéphalique secondaire à une cause neurologique. En conclusion, la mort encéphalique survient chez environ 16% des victimes d arrêt cardio-circulatoire réanimés avec succès ce qui en fait des donneurs potentiels. Même en présence d un pronostic vital compromis après un arrêt cardio-circulatoire, les efforts de réanimation et le support hémodynamique doivent être poursuivis et le don d organe doit être envisagé.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

ETUDES DES EFFETS PULMONAIRES ET SYSTEMATIQUES DU MONOXYDE D'AZOTE INHALE

PARIS-BIUSJ-Physique recherche (751052113) / SudocCentre Technique Livre Ens. Sup. (774682301) / SudocSudocFranceF