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/)

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Impact d'une formation supportée par une plate-forme informatique sur l'enseignement des bases fondamentales en Anesthésie-Réanimation

L'e-learning émerge depuis plusieurs années dans la pédagogie médicale grâce à l'essor d'Internet et de l'informatisation personnelle. Dans cette mouvance, il a été créé à partir du site Internet de la faculté de médecine de Rouen, une plate-forme informatique regroupant l'enseignement des bases fondamentales d'Anesthésie-Réanimation. L'objectif de ce travail a été d'évaluer si un enseignement de type "blended-learning" (plate-forme informatique associée à des cours présentiels) permettait l'amélioration des résultats à l'examen de fin d'année. Matériel et méthodes : Nous avons mené une étude multi-centrique, non randomisée qui incluait les DESAR de 1re année des facultés de médecine d'Amiens, Caen et Rouen sur les années 2010, 2011 et 2012. L'e-learning a été instauré en 2011 à Caen et Rouen, par contre à Amiens, l'enseignement est resté traditionnel sous la forme de cours magistraux (groupe contrôle). En 2012, les DESAR Rouennais ont bénéficié de l'e-learning alors que les DESAR de Caen et Amiens formaient le groupe contrôle. Le paramètre principal était la note médiane des internes à l'examen de fin d'année. Les paramètres secondaires étaient le temps de travail auto-évalué, la satisfaction des DESAR vis-à-vis de cet enseignement et le rang ECN des différentes cohortes. Résultats : En 2011, il y avait une différence significative entre le groupe e-learning et le groupe contrôle (p<0.001) sans différence significative en termes de rangs aux ECN (p=0,15). En 2012, la différence est également significative (p<0.05) entre les deux groupes, avec une différence significative au niveau des rangs ECN (p=0.02). Il y avait une augmentation du temps de travail entre les deux sessions, 5 à 10h pour la première contre près de 20h pour la deuxième. Conclusion : L'e-learning a permis une amélioration des résultats à l'examen de fin d'année. Cela semble s'expliquer en grande partie par une augmentation du temps de travail personnel stimulé par la plate-forme informatique

Impact d une formation supportée par une plate-forme informatique sur l enseignement des bases fondamentales en Anesthésie-Réanimation

Introduction : L e-learning émerge depuis plusieurs années dans la pédagogie médicale grâce à l essor d Internet et de l informatisation personnelle. Dans cette mouvance, il a été créé à partir du site Internet de la faculté de médecine de Rouen, une plate-forme informatique regroupant l enseignement des bases fondamentales d Anesthésie-Réanimation. L objectif de ce travail a été d évaluer si un enseignement de type blended-learning (plate-forme informatique associée à des cours présentiels) permettait l amélioration des résultats à l examen de fin d année. Matériel et méthodes : Nous avons mené une étude multi-centrique, non randomisée qui incluait les DESAR de 1ère année des facultés de médecine d Amiens, Caen et Rouen sur les années 2010, 2011 et 2012. L e-learning a été instauré en 2011 à Caen et Rouen, par contre à Amiens, l enseignement est resté traditionnel sous la forme de cours magistraux (groupe contrôle). En 2012, les DESAR Rouennais ont bénéficié de l e-learning alors que les DESAR de Caen et Amiens formaient le groupe contrôle. Le paramètre principal était la note médiane des internes à l examen de fin d année. Les paramètres secondaires étaient le temps de travail auto-évalué, la satisfaction des DESAR vis-à-vis de cet enseignement et le rang ECN des différentes cohortes. Résultats : En 2011, il y avait une différence significative entre le groupe e-learning et le groupe contrôle (p<0.001) sans différence significative en termes de rangs aux ECN (p=0,15). En 2012, la différence est également significative (p<0.05) entre les deux groupes, avec une différence significative au niveau des rangs ECN (p=0.02). Il y avait une augmentation du temps de travail entre les deux sessions, 5 à 10h pour la première contre près de 20h pour la deuxième. Conclusion : L e-learning a permis une amélioration des résultats à l examen de fin d année. Cela semble s expliquer en grande partie par une augmentation du temps de travail personnel stimulé par la plate-forme informatique.ROUEN-BU Médecine-Pharmacie (765402102) / SudocSudocFranceF

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

Effectiveness of a blended learning course and flipped classroom in first year anaesthesia training

International audienceBackground: Blended learning, which combines internet-based platform and lecturing, is used in anaesthesiology and critical care teaching. However, the benefits of this method remain unclear. Methods: We conducted a prospective, multicentre, non-randomised work between 2007 and 2014 to study the effect of blended learning on the results of first year anaesthesia and critical care residents in comparison with traditional teaching. Blended learning was implemented in Rouen University Hospital in 2011 and residents affiliated to this university corresponded as the blended learning group. The primary outcome was the resident's results as measured with multiple-choice questions between blended learning and control groups after beginning blended learning (post-interventional stage). The secondary outcomes included residents' results between pre and post-interventional stages and homework's time. Moreover, comparison between control and blended learning group before beginning blended learning (pre-interventional stage) was performed. Results: From 2007 to 2014, 308 residents were included. For the pre-interventional period, the mean score in the blended learning group (n = 53) was 176 (CI 95% 163 to 188) whereas the mean score in the control group (n = 106) was 167 (CI 95% 160 to 174) (no difference). For the post-interventional period, the mean score in blended learning group (n = 54) was 232 on 300 (CI95% 227-237) whereas the mean score in the control group (n = 95) is 215 (CI95% 209-220) (P < 0.001). In the two groups, comparison between pre and post-interventional stages showed the increase of mean score, stronger for blended learning group (32% and 28% in blended learning and control group, P < 0.05). The average time of homework in the blended learning group was 27 h (CI 95% 18.2-35.8) and 10 h in the control group (CI 95% 2-18) (P < 0.05). Conclusions: This work suggests the positive effect of blended learning (associating internet-based learning and flipped classroom) on the anaesthesia and critical care residents' knowledge by increasing their homework's time. (C) 2017 Published by Elsevier Masson SAS on behalf of Societe francaise d'anesthesie et de reanimation (Sfar)

The Use of Ferritin to Identify Critically Ill Patients With Secondary Hemophagocytic Lymphohistiocytosis*

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Severe serotonin syndrome caused by an interaction between an antidepressant and a cough syrup

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