An integrated approach for prescribing fewer chest x-rays in the ICU

Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Etude des propriétés mécaniques des cellules épithéliales alvéolaires dans le SDRA par la technique de magnétocytométrie

Le SDRA se définit par une atteinte inflammatoire intense localisée au poumon, sa principale caractéristique mécanique étant une baisse de la compliance. Le traitement repose sur la ventilation mécanique, qui peut aggraver les lésions préexistantes. Nous avons étudié les interactions entre contrainte mécanique et médiateurs inflammatoires à la phase aiguë du SDRA. La magnécytométrie permet de générer un stress mécanique sur des cellules épithéliales alvéolaires humaines (A549) en culture et d'en mesurer certaines propriétés mécaniques (rigidité globale et des compartiments cortical et profond du cytosquelette). Le LBA est prélevé chez des patients atteints de SDRA et chez des sujets atteints d'OAP dans les 24 premières heures. Les cellules sont exposées à du surnageant de LBA-SDRA, LBA-OAP, à du TNFa ou à de l'IL1-b. Le marquage de l'actine, dans les mêmes conditions, permet d'étudier la formation de fibres de stress. L'utilisation de cytochalasine D permet d'analyser l'effet sur la rigidité après dépolymérisation des fibres d'actine. La rigidité globale et des deux compartiments du cytosquelette est significativement augmentée dans le groupe SDRA par rapport au groupe OAP. Cette augmentation de rigidité est associée à la formation de fibres de stress et est diminuée après dépolymérisation de l'actine par la cytochalasine D. Ni le TNFa ni l'IL1-b n'induisent de modification des propriétés mécaniques du cytosquelette. Nous avons trouvé une majoration de la rigidité du cytosquelette des cellules épithéliales alvéolaires exposées à un environnement reproduisant le SDRA, montrant pour la première fois une altération des propriétés mécaniques au niveau cellulaireARDS is defined by an intense inflammation localized to the lung and is characterized by an increased lung elastance. Treatment relies on mechanical ventilation, which can worsen pre-existing lesions. We studied the interactions between mechanical strain and inflammatory mediators at the acute phase of ARDS. Magnetic twisting cytometry allows to generate a mechanical stress on cultured human alveolar epithelial cells (A549) and to measure some of their mechanical properties (global cytoskeleton stiffness, cortical and cytosolic cytoskeleton components stiffness). Bronchoalveolar lavage samples are performed in patients suffering either from ARDS or hydrostatic lung edema within the first 24 hours. Cells are exposed to supernatant of ARDS-BAL, HLE-BAL, TNFa or IL1-b. Actin immunostaining, in the same conditions, permits to study stress fibers formation. Cytochalasin D allows to analyze the effect of actin depolymerisation on cytoskeleton stiffness. Both global and each cytoskeleton components stiffness are significantly increased in ARDS group compared to HLE group. This effect is associated to a stress fibers formation and is decreased after actin depolymerisation by cytochalasin D. Neither TNFa nor IL1-b induces cytoskeleton mechanical properties modifications. We found an increase of cytoskeleton stiffness in alveolar epithelial cells exposed to an inflammatory environment mimicking ARDS, showing for the first time mechanical properties alterations at the cellular levelPARIS12-CRETEIL BU Médecine (940282101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Postoperative peritonitis without an underlying digestive fistula after complete cytoreductive surgery plus HIPEC

Background/Aim: Peritoneal carcinomatosis (PC) is a pernicious event associated with a dismal prognosis. Complete cytoreductive surgery (CCRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is able to yield an important survival benefit but at the price of a risky procedure inducing potentially severe complications. Postoperative peritonitis after abdominal surgery occurs mostly when the digestive lumen and the peritoneum communicate but in rare situation, no underlying digestive fistula can be found. The aim of this study was to report this situation after CCRS plus HIPEC, which has not been described yet and for which the treatment is not yet well defined. Patients and Methods: Between 1994 and 2012, 607 patients underwent CCRS plus HIPEC in our tertiary care center and were retrospectively analyzed. Results: Among 52 patients (9%) reoperated for postoperative peritonitis, no digestive fistula was found in seven (1%). All had a malignant peritoneal pseudomyxoma with an extensive disease (median Peritoneal Cancer Index: 27). The median interval between surgery and reoperation was 8 days [range: 3-25]. Postoperative mortality was 14%. Five different bacteriological species were identified in intraoperative samples, most frequently Escherichia coli (71%). The infection was monobacterial in 71%, with multidrug resistant germs in 78%. Conclusions: Postoperative peritonitis without underlying fistula after CCRS plus HIPEC is a rare entity probably related to bacterial translocation, which occurs in patients with extensive peritoneal disease requiring aggressive surgeries. The principles of treatment do not differ from that of other types of postoperative peritonitis

Bacterial colonization of healthcare workers’ mobile phones in the ICU and effectiveness of sanitization

International audienceExtra-European studies report high rates of multi-drug resistant bacteria colonization of healthcare workers' mobile phones in intensive care units. We aimed to assess the prevalence of bacterial colonization of healthcare workers' mobile phones in an intensive care unit in France and the effectiveness of a sanitization product. We designed a prospective, monocentric study in a 15-bed intensive care unit within a 300-bed private hospital. Bacterial colonization was assessed on 56 healthcare workers' mobile phones immediately before and 5 min after sanitization of the phones with bactericidal wipes. The mobile phones of 42 administrative staff acted as controls. All mobile phones in both groups were colonized. Healthcare workers' phones had a higher number of different bacterial species per phone (2.45 ± 1.34 vs. 1.81 ± 0.74, p = 0.02). Colonization with pathogens did not differ significantly between healthcare workers' and controls' phones (39.3% vs. 28.6%, p = 0.37). Excluding coagulase negative Staphylococcus, Staphylococcus aureus was the most common pathogen found in both groups (19.6% and 11.9%, p = 0.41). Only one healthcare workers' mobile phone was colonized by methicillin-resistant Staphylococcus aureus, and no other multi-drug resistant bacteria was detected. No covariate was associated with pathogen colonization. After sanitization, 8.9% of mobile phones were sterilized, and colonization with pathogenic bacteria decreased (21.4% vs. 39.3%, p = 0.04) as did the number of CFUs/mL (367 ± 404 vs. 733 ± 356, p < 0.001). Colonization of intensive care unit healthcare workers' and administrative staff's mobile phones was similar. Colonization with pathogens was frequent but colonization with multi-drug resistant bacteria was rare. Disinfecting the phones with bactericidal wipes is not completely effective. Specific sanitization protocols and recommendations regarding the management of healthcare workers' mobile phones in intensive care units should be developed. Additionally, good hand hygiene after touching mobile phones should be kept in mind to prevent cross-infections

Patients in ICUs Indications of Chest Radiographs for A Web-Based Delphi Study on the Indications of Chest Radiographs for Patients in ICUs*

Detailed feedback for the answers given during the previous round was supplied to each intensivist solicited for updating his answers. Results: Eighty-two intensivists from 32 ICUs completed the study. A consensus emerged that routine CXRs were necessary for eight scenarios and unnecessary for two scenarios. The study also shed light on items without a consensus. In particular, 75% of intensivists (58% on the first round) did not support obtaining daily routine CXRs in intubated patients. Conclusion: The study underlines situations in which intensivists do not support the guidelines and outlines recommendations likely to be followed in clinical practice

Giving a voice to patients at high risk of dying in the intensive care unit: a multiple source approach

Purpose Data are scarce regarding the experience of critically ill patients at high risk of death. Identifying their concerns could allow clinicians to better meet their needs and align their end-of-life trajectory with their preferences and values. We aimed to identify concerns expressed by conscious patients at high risk of dying in the intensive care unit (ICU). Methods Multiple source multicentre study. Concerns expressed by patients were collected from five different sources (literature review, panel of 50 ICU experts, prospective study in 11 ICUs, in-depth interviews with 17 families and 15 patients). All qualitative data collected were analyzed using thematic content analysis. Results The five sources produced 1307 concerns that were divided into 7 domains and 41 sub-domains. After removing redundant items and duplicates, and combining and reformulating similar items, 28 concerns were extracted from the analysis of the data. To increase accuracy, they were merged and consolidated, and resulted in a final list of 15 concerns pertaining to seven domains: concerns about loved-ones; symptom management and care (including team competence, goals of care discussions); spiritual, religious, and existential preoccupations (including regrets, meaning, hope and trust); being oneself (including fear of isolation and of being a burden, absence of hope, and personhood); the need for comforting experiences and pleasure; dying and death (covering emotional and practical concerns); and after death preoccupations. Conclusion This list of 15 concerns may prove valuable for clinicians as a tool for improving communication and support to better meet the needs of patients at high risk of dying