Prévention des infections liées aux soins en réanimation

Les services de réanimation rassemblent les malades les plus à risque de complications infectieuses en raison de leur extrême gravité et de leur exposition à de nombreux dispositifs invasifs. Une partie de ces infections nosocomiales, notamment celle liées aux soins est probablement évitable en mettant au point des mesures de prévention efficaces. Cette thèse présente les travaux que nous avons menés dans ce domaine ; la première partie étant consacrée à la prévention des pneumopathies acquises sous ventilation mécanique (PAVM) et la deuxième à la prévention de la transmission croisée manuportée. Nous avons montré que le recours à la ventilation non invasive en remplacement de la ventilation invasive conventionnelle était associé à une diminution significative non seulement des PAVM, mais également d autres types d infections. En revanche, le drainage continu des sécrétions sous-glottiques combiné à la position demi-assise ne semblait pas avoir d effet sur la colonisation oro-trachéale des malades intubés et ventilés, étape physiopathologique préalable au développement des PAVM. Nous avons également montré que l utilisation de la friction hydro-alcoolique, un usage raisonné des gants de soins et le dépistage ciblé des staphylocoques dorés multirésistants devaient être proposées pour limiter la transmission croisée manuportée en réanimation.Patients hospitalized in intensive care units are at high-risk of acquiring infections because of their high severity and high exposure to invasive devices. One part of these infections may probably be avoided using effective measures, especially the part associated with care activities. This thesis presents the studies we conducted in this field with a first part focusing on the prevention of ventilator-associated pneumonia (VAP) and a second part discussing the prevention of cross transmission via hands. For VAP prevention, the use of noninvasive ventilation was associated with a significant reduction of VAP and other sites of infection whereas, in another study, the use of subglottic secretions drainage and semi-recumbent position had no effect on tracheal colonization, which normally precedes lung infection. We also demonstrated that the use of alcoholic hand-rubs, the rational use of gloves and, the screening of multiresistant Staphylococcus aureus on admission might help limiting cross transmission of microorganisms in intensive care units.PARIS12-CRETEIL BU Multidisc. (940282102) / SudocSudocFranceF

Do hypooncotic fluids for shock increase the risk of late-onset acute respiratory distress syndrome?

OBJECTIVE: In patients with shock, late-onset acute respiratory distress syndrome (ARDS) carries poor prognosis. Hypooncotic fluids may improve kidney function preservation, whereas hyperoncotic fluids may in theory decrease the risk of late-onset ARDS. Our objective was to determine whether predominant or exclusive use of crystalloids and/or hypooncotic colloids for shock resuscitation influenced the risk of late-onset ARDS. PARTICIPANT AND SETTINGS: International prospective cohort of consecutive adults who were free of ARDS on admission and who received fluid resuscitation for shock in 115 intensive care units (ICUs) during a 4-week period. MEASUREMENTS AND RESULTS: Severity scores, hemodynamic status, indication for fluids, risk factors for ARDS, plasma expander use, transfusions, and late-onset ARDS were recorded prospectively. Logistic regression models were tested to determine whether predominant or exclusive use of hypooncotic fluids was associated with higher incidence of late-onset ARDS. Of 905 patients, 81 [8.9%; 95% confidence interval (CI) 7.2-11.0] developed ARDS, with no difference between patients given only hypooncotic fluids (10.4%; 95% CI 7.6-13.7) and the other patients (7.7%; 95% CI 5.5-10.5; p = 0.16). Late-onset ARDS was significantly associated with sepsis [odds ratio (OR) 1.90; 95% CI 1.06-3.40], worse chest X-ray score at fluid initiation (1.55; 95% CI 1.27-1.91), positive fluid balance (1.06 per l; 95% CI 1.02-1.09), and greater transfusion volume (1.14 per l; 95% CI 1.01-1.29). The proportion of hypooncotic fluids in the plasma expander regimen was not associated with late-onset ARDS (1.01 per %; 95% CI 0.99-1.01). CONCLUSIONS: Based on this observational study, there is no evidence that in patients with shock the use of hypooncotic fluids increases the risk of late-onset ARDS. This finding needs to be confirmed

The risk associated with hyperoncotic colloids in patients with shock

International audienceObjective Crystalloids, artificial and natural colloids have been opposed as representing different strategies for shock resuscitation, but it may be relevant to distinguish fluids based on their oncotic characteristics. This study assessed the risk of renal adverse events in patients with shock resuscitated using hypooncotic colloids, artificial hyperoncotic colloids, hyperoncotic albumin or crystalloids, according to physician’s choice. Participants and setting International prospective cohort study including 1,013 ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis or receiving plasma were excluded. Measurements and results Influence of different types of colloids and crystalloids on the occurrence of renal events (twofold increase in creatinine or need for dialysis) and mortality was assessed using multivariate analyses and propensity score. Statistical adjustment was based on severity at the time of resuscitation, risks factor for renal failure, and on variables influencing physicians’ preferences regarding fluids. A renal event occurred in 17% of patients. After adjustment on potential confounding factors and on propensity score for the use of hyperoncotic colloids, the use of artificial hyperoncotic colloids [OR: 2.48 (1.24–4.97)] and hyperoncotic albumin [OR: 5.99 (2.75–13.08)] was significantly associated with occurrence of renal event. Overall ICU mortality was 27.1%. The use of hyperoncotic albumin was associated with an increased risk of ICU death [OR: 2.79 (1.42–5.47)]. Conclusions This study suggests that harmful effects on renal function and outcome of hyperoncotic colloids may exist. Although an improper usage of these compounds and confounding factors cannot be ruled out, their use should be regarded with caution, especially because suitable alternatives exist.</p

The risk associated with hyperoncotic colloids in patients with shock

Crystalloids, artificial and natural colloids have been opposed as representing different strategies for shock resuscitation, but it may be relevant to distinguish fluids based on their oncotic characteristics. This study assessed the risk of renal adverse events in patients with shock resuscitated using hypooncotic colloids, artificial hyperoncotic colloids, hyperoncotic albumin or crystalloids, according to physician's choice. International prospective cohort study including 1,013 ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis or receiving plasma were excluded. Influence of different types of colloids and crystalloids on the occurrence of renal events (twofold increase in creatinine or need for dialysis) and mortality was assessed using multivariate analyses and propensity score. Statistical adjustment was based on severity at the time of resuscitation, risks factor for renal failure, and on variables influencing physicians' preferences regarding fluids. A renal event occurred in 17% of patients. After adjustment on potential confounding factors and on propensity score for the use of hyperoncotic colloids, the use of artificial hyperoncotic colloids [OR: 2.48 (1.24-4.97)] and hyperoncotic albumin [OR: 5.99 (2.75-13.08)] was significantly associated with occurrence of renal event. Overall ICU mortality was 27.1%. The use of hyperoncotic albumin was associated with an increased risk of ICU death [OR: 2.79 (1.42-5.47)]. This study suggests that harmful effects on renal function and outcome of hyperoncotic colloids may exist. Although an improper usage of these compounds and confounding factors cannot be ruled out, their use should be regarded with caution, especially because suitable alternatives exist

Description and Microbiology of Endotracheal Tube Biofilm in Mechanically Ventilated Subjects

International audienceBACKGROUND: A biofilm is found on the inner side of endotracheal tubes (ETT) in mechanically ventilated patients, but its features and role in pneumonia remain unclear. METHODS: This prospective, observational, monocentric study included critically ill ventilated subjects. Measurement of the ETT inner volume was first performed before exhibation using the acoustic reflection method. After extubation, the biofilm was studied by means of optical and atomic force microscopy. Bacteriological analysis was then performed and compared with clinical documentation. RESULTS: Twenty-four subjects were included. Duration of intubation lasted from 2 to 79 d (mean +/- SD: 11 +/- 15 d). The mean percentage of ETT volume loss evaluated in situ (n = 21) was 7.1% and was not linked with the duration of intubation. Analyses with atomic force microscopy (n = 6) showed a full coverage of the inner part of the tube with biofilm, even after saline rinse. Its thickness ranged from 0.8 to 5 mu m. Bacteriological cultures of the biofilm (n = 22) often showed the same bacteria as in tracheal secretions, especially for pathogenic organisms. Pseudomonas aeruginosa and Candida albicans were among the most frequent microorganisms. In subjects who had experienced a successfully treated episode of ventilator-associated pneumonia (n = 5), the responsible bacteria were still present in the biofilm. CONCLUSIONS: ETT biofilm is always present in intubated patients whatever the duration of intubation and appears quickly after intubation. Even after soft rinse, a small but measurable part of biofilm remains always present, and seems strongly adherent to the ETT lumen. It contains potentially pathogenic bacteria for the lung