PathFinder 2015

担当教員:姉川雄大平成27年度(2015)教養展開科目(国際コア関連),授業コード:Ｇ15N1060

Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients – A prospective multicenter observational study (iSOFA study)

Background & aims: To develop a five grade score (0–4 points) for the assessment of gastrointestinal (GI) dysfunction in adult critically ill patients. Methods: This prospective multicenter observational study enrolled consecutive adult patients admitted to 11 intensive care units in nine countries. At all sites, daily clinical data with emphasis on GI clinical symptoms were collected and intra-abdominal pressure measured. In five out of 11 sites, the biomarkers citrulline and intestinal fatty acid-binding protein (I-FABP) were measured additionally. Cox models with time-dependent scores were used to analyze associations with 28- and 90-day mortality. The models were estimated with stratification for study center. Results: We included 540 patients (224 with biomarker measurements) with median age of 65 years (range 18–94), the Simplified Acute Physiology Score II score of 38 (interquartile range 26–53) points, and Sequential Organ Failure Assessment (SOFA) score of 6 (interquartile range 3–9) points at admission. Median ICU length of stay was 3 (interquartile range 1–6) days and 90-day mortality 18.9%. A new five grade Gastrointestinal Dysfunction Score (GIDS) was developed based on the rationale of the previously developed Acute GI Injury (AGI) grading. Citrulline and I-FABP did not prove their potential for scoring of GI dysfunction in critically ill. GIDS was independently associated with 28- and 90-day mortality when added to SOFA total score (HR 1.40; 95%CI 1.07–1.84 and HR 1.40; 95%CI 1.02–1.79, respectively) or to a model containing all SOFA subscores (HR 1.48; 95%CI 1.13–1.92 and HR 1.47; 95%CI 1.15–1.87, respectively), improving predictive power of SOFA score in all analyses. Conclusions: The newly developed GIDS is additive to SOFA score in prediction of 28- and 90-day mortality. The clinical usefulness of this score should be validated prospectively. Trial registration: NCT02613000, retrospectively registered 24 November 2015.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Non-réadmissions en réanimation‎ : enquête de pratiques

L’admission d’un patient en réanimation est à mettre en balance avec le bénéfice qui en est potentiellement attendu. Ainsi, certains patients ne sont pas admis en réanimation en argumentant d’un risque de décès élevé ou d’une qualité de vie devenue inacceptable au décours de l’hospitalisation le cas échéant, rendant cette dernière « futile ». Alors que les réadmissions en réanimation ont un réel impact sur la morbi-mortalité, certains patients dont le parcours en réanimation a été particulièrement difficile font l’objet d’une décision de « non-réadmission » en réanimation si l’indication devait à nouveau se poser. Les décisions de « non-admission » et de « non-réadmission » en réanimation sont des décisions de limitation ou d’arrêt des thérapeutiques (LAT), telles qu’elles ont été définies par la loi du 22 avril 2005 dite « loi Leonetti » car elles conduisent à une limitation de moyens face à un patient dont la vie est (potentiellement) en danger. À notre connaissance, aucun travail publié jusqu’alors n’a étudié les décisions de « non-réadmission » en réanimation. L’objectif de notre étude est de réaliser une évaluation des pratiques professionnelles relatives aux décisions de non-réadmission en réanimation. Matériel et Méthodes : Entre le 01 décembre 2015 et le 31 janvier 2016, des médecins réanimateurs ont été sollicités par voie électronique pour répondre à un questionnaire sur le thème de la non-réadmission. Le questionnaire, comportant 27 questions, a été élaboré à l’aide d’un sociologue selon une méthodologie validée dans la littérature. Les variables qualitatives ont été exprimées en pourcentages et ont été comparées en utilisant le test du Chi-2 ou le test exact de Fischer. Résultats : Cent soixante-cinq médecins ont répondu au questionnaire. Les décisions de non-réadmission sont prises majoritairement en fin de séjour en réanimation (87% des cas) suite à une discussion collégiale (89% des cas). Néanmoins, les patients, les proches (et/ou famille), un médecin consultant extérieur ou le généraliste ne sont impliqués dans la prise de décision que de manière marginale (à hauteur respectivement de 10%, 34%, 14% et 29%). Si 73% des proches sont informés de ce type de décision, moins d’un tiers des patients ont reçu cette information. Une fois la décision prise, celle-ci est notifiée dans le dossier du patient dans 93% des cas. Cependant, 96% des répondeurs considèrent avoir la possibilité de ne pas tenir compte de cette décision le cas échéant. De plus, pour 92% des médecins, il existe clairement une différence entre une demande de réadmission pour un épisode aigu intercurrent et pour une aggravation d’une pathologie chronique. Par ailleurs, une prise en charge palliative n’est décidée de manière conjointe à la décision de non-réadmission dans seulement 41% des cas. Enfin, 91% des répondeurs considèrent que les décisions de non-réadmission font partie intégrante de la loi du 22 avril 2005. Discussion : Notre travail met en évidence un processus décisionnel insuffisamment rigoureux sur les plans légal et éthique, notamment sur l’implication des patients dans la prise de décision concernant leur santé, sur l’information des patients, sur l’intervention d’un consultant extérieur ou encore la mise en place d’une démarche palliative. Afin de répondre à ces impératifs et à la demande d’autonomisation des patients, notre travail aboutit à la proposition d’une procédure de discussion de non-réadmission en intégrant celle-ci dans un réel projet de soins pour le patient à la sortie de réanimation. Ce projet de soins permettrait de prendre l’avis du patient sous forme de directives anticipées « éclairées », de s’assurer d’une discussion collégiale faisant intervenir un consultant extérieur, de permettre une réévaluation du patient dans sa globalité et face à une ou plusieurs défaillances aiguës, et d’intégrer la question de non-réadmission au sein d’un réel projet thérapeutique pour le patient en promouvant une éventuelle démarche palliative le cas échéant

Ethical aspects of admission or non-admission to the intensive care unit

International audienceThe question of admission and non-admission to the intensive care unit (ICU) raises several ethical questions. There is a fine line between the risk of loss-of-opportunity for the patient in case of non-admission, and the risk of unreasonable therapeutic obstinacy, in case of unjustified admission. Similar difficulties arise in decisions regarding re-admission or non-re-admission, with the sole difference that the intensivists already know the patient and his/her medical history. This information can help inform the decision when re-admission is being considered. Intensive, i.e., life-sustaining care should be implemented after shared reflection involving the caregivers, the patient and the family, and the same applies for non-implementation of these same therapies. Anticipating admission or non-admission to the ICU in case of acute organ failure, or in case of potential deterioration represents a major challenge for our discipline in the coming years

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices

International audiencePurpose: We investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation.Materials and methods: Multicentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents’ practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission.Results: In total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient’s stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient’s medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework.Conclusion: This study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient’s individual characteristics

The prognostic value of the neutrophil-to-lymphocyte ratio in critically ill cirrhotic patients

International audienceHospital death rates following ICU admission of cirrhotic patients remain high. Identifying patients at high risk of mortality after few days of aggressive management is imperative for providing adequate interventions. Herein, we aimed to evaluate the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) combined with usual organ failure scores in the outcome prediction of cirrhotic patients hospitalized more than 3 days in ICU

Limitation of life-sustaining therapies in critically ill patients with COVID-19 : a descriptive epidemiological investigation from the COVID-ICU study

Background: Limitations of life-sustaining therapies (LST) practices are frequent and vary among intensive care units (ICUs). However, scarce data were available during the COVID-19 pandemic when ICUs were under intense pressure. We aimed to investigate the prevalence, cumulative incidence, timing, modalities, and factors associated with LST decisions in critically ill COVID-19 patients. Methods: We did an ancillary analysis of the European multicentre COVID-ICU study, which collected data from 163 ICUs in France, Belgium and Switzerland. ICU load, a parameter reflecting stress on ICU capacities, was calculated at the patient level using daily ICU bed occupancy data from official country epidemiological reports. Mixed effects logistic regression was used to assess the association of variables with LST limitation decisions. Results: Among 4671 severe COVID-19 patients admitted from February 25 to May 4, 2020, the prevalence of in-ICU LST limitations was 14.5%, with a nearly six-fold variability between centres. Overall 28-day cumulative incidence of LST limitations was 12.4%, which occurred at a median of 8 days (3-21). Median ICU load at the patient level was 126%. Age, clinical frailty scale score, and respiratory severity were associated with LST limitations, while ICU load was not. In-ICU death occurred in 74% and 95% of patients, respectively, after LST withholding and withdrawal, while median survival time was 3 days (1-11) after LST limitations. Conclusions: In this study, LST limitations frequently preceded death, with a major impact on time of death. In contrast to ICU load, older age, frailty, and the severity of respiratory failure during the first 24 h were the main factors associated with decisions of LST limitations.</p

Summary of the French LST limitation decision-making process.

Summary of the French LST limitation decision-making process.</p

Minimal data set.

IntroductionConflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs.MethodsBetween June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians.ResultsAmong 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient’s wishes would help avoid these conflicts.ConclusionTeam-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.</div