Valeur ajoutée d'un système d'information clinique aux soins intensifs

Depuis 30 ans au moins, les équipes médico-infirmières rêvent de systèmes informatiques pouvant intégrer la masse des données produites par et pour les patients. Il s'agit de trier, d'organiser et de resituer des informations de nature très variée d'une manière structurée et utilisable . L'informatisation des unités de soins intensifs (SI) du CHUV est un projet institutionnel "Hospices-CHUV", portant l'acronyme "SICASI", pour "système d'information clinique aux soins intensifs". Le projet concerne 41 lits de SI situés au niveau 05 du bâtiment hospitalier principal : ces lits sont répartis en trois unités, chirurgicale (17 lits), médicale (14 lits), et pédiatrique (10 lits). Le budget global dévolu à l'informatisation est de 2,5 millions de francs. Le projet a d'emblée été multidisciplinaire, englobant des médecins et des infirmiers des 3 unités, ainsi que des informaticiens. Il devrait aboutir à un changement fondamental de la manière de travailler en SI. [Extrait de l'introduction, p. 2]]]> Intensive Care Units ; Hospital Information Systems ; Medical Records Systems, Computerized ; Hospitals, University fre https://serval.unil.ch/resource/serval:BIB_C9A8235D6023.P001/REF.pdf http://nbn-resolving.org/urn/resolver.pl?urn=urn:nbn:ch:serval-BIB_C9A8235D60232 info:eu-repo/semantics/altIdentifier/urn/urn:nbn:ch:serval-BIB_C9A8235D60232 info:eu-repo/semantics/openAccess Copying allowed only for non-profit organizations https://serval.unil.ch/disclaimer application/pdf oai:serval.unil.ch:BIB_C9A972CD5FE4 2022-05-07T01:26:59Z <oai_dc:dc xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:xs="http://www.w3.org/2001/XMLSchema" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:oai_dc="http://www.openarchives.org/OAI/2.0/oai_dc/" xsi:schemaLocation="http://www.openarchives.org/OAI/2.0/oai_dc/ http://www.openarchives.org/OAI/2.0/oai_dc.xsd"> https://serval.unil.ch/notice/serval:BIB_C9A972CD5FE4 Postoperative 3D conformal radiation therapy with dose-volume histogram assessment in non small-cell lung cancer info:doi:10.1016/j.ijrobp.2007.07.1713 info:eu-repo/semantics/altIdentifier/doi/10.1016/j.ijrobp.2007.07.1713 Zouhair, A. Drausanu, D. Matzinger, O. Pehlivan, B. Khanfir, K. Ris, H.B. Stupp, R. Moeckli, R. Mirimanoff, R.O. Ozsahin, M. info:eu-repo/semantics/conferenceObject inproceedings 2007 49th Annual Meeting of the American Society for Therapeutic Radiology and Oncology, vol. 69, pp. S498-S499 info:eu-repo/semantics/altIdentifier/isbn/0360-3016 <![CDATA[Purpose/Objective(s): Despite many randomized trials, the indication of postoperative radiation therapy (PORT) in non small cell lung cancer (NSCLC) is controversial. Involved-field conformal (3D) RT has never been studied prospectively. In this study, we aim to assess the outcome of patients treated with involved-field 3D PORT with or without chemotherapy in locally advanced NSCLC. Materials/Methods: From 1990 to 2006, data from 75 consecutive patients treated with curative surgery and PORT for NSCLC were retrospectively analyzed. Male to female ratio was 57/18, and median age was 58 years (38-76). There were 5 patients with stage I, 22 with stage II, and 48 with stage III disease. Pneumonectomy or lobectomy was realized in 24 and 51 patients, respectively. Mediastinal lymphadenectomy was performed in all patients. PORT indications were positive margins and/or positive mediastinal lymph nodes. Cisplatin-based chemotherapy was given in 15 patients. All patients had 3D conformal planning. Median RT dose was 60 Gy using at least 6-MV photons in 6 weeks, and CTV included bronchial stump and only positive nodal areas. Dose-volume histograms (DVH) assessing the pulmonary volume receiving 20 Gy (V20 Gy) were used in all patients. Results: Compliance to PORT was 100%. In a median follow-up period of 55 months, 26 (35%) patients are alive without disease. Median overall survival time was 24 months, with survival rate of 35% at 5 years (Fig. 1). The 5-year locoregional control and distant disease-free rates were 80% and 57%, respectively. Patients treated with pneumonectomy and those treated with at least 60-Gy PORT had better outcome (Fig. 2). Grade 3 or more CTC v3.0 toxicity was observed only in 4 (5%) pts. No lethal toxicity was observed. Conclusions: We conclude that involved-field 3D conformal 60-Gy PORT tailored with DVH V20 Gy assessment improves locoregional control without increasing lethal toxicity. Prospective studies using the above-mentioned criteria are warranted

Feed the ICU patient 'gastric' first, and go post-pyloric only in case of failure

In a randomised trial comparing early enteral feeding by gastric and post-pyloric routes, White and colleagues have shown that gastric feeding is possible and efficient in the vast majority of critically ill patients. But the authors' conclusion that gastric is equivalent to post-pyloric is true in only the least severe patients. Given the extra workload and costs, post-pyloric is now clearly indicated in case of gastric feeding failure

Micronutrients to Support Vaccine Immunogenicity and Efficacy

The world has entered the third year of the coronavirus disease 2019 (COVID-19) pan-demic. Vaccination is the primary public health strategy to protect against infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in addition to other measures, such as mask wearing and social distancing. Vaccination has reduced COVID-19 severity and mortality dramatically. Nevertheless, incidence globally remains high, and certain populations are still at risk for severe outcomes. Additional strategies to support immunity, including potentially enhancing the response to vaccination, are needed. Many vitamins and trace minerals have recognized immunomodulatory actions, and their status and/or supplementation have been reported to corre-spond to the incidence and severity of infection. Furthermore, a variety of observational and some interventional studies report that adequate micronutrient status or micronutrient supplementation is associated with enhanced vaccine responses, including to COVID-19 vaccination. Such data suggest that micronutrient supplementation may hold the potential to improve vaccine immunogenicity and effectiveness, although additional interventional studies to further strengthen the existing evidence are needed. Positive findings from such research could have important implications for global public health, since deficiencies in several micronutrients that support immune function are prevalent in numerous settings, and supplementation can be implemented safely and inexpensively

Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients

INTRODUCTION: Oxidative stress is involved in the development of secondary tissue damage and organ failure. Micronutrients contributing to the antioxidant (AOX) defense exhibit low plasma levels during critical illness. The aim of this study was to investigate the impact of early AOX micronutrients on clinical outcome in intensive care unit (ICU) patients with conditions characterized by oxidative stress. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled, single-center trial in patients admitted to a university hospital ICU with organ failure after complicated cardiac surgery, major trauma, or subarachnoid hemorrhage. Stratification by diagnosis was performed before randomization. The intervention was intravenous supplements for 5 days (selenium 270 microg, zinc 30 mg, vitamin C 1.1 g, and vitamin B1 100 mg) with a double-loading dose on days 1 and 2 or placebo. RESULTS: Two hundred patients were included (102 AOX and 98 placebo). While age and gender did not differ, brain injury was more severe in the AOX trauma group (P = 0.019). Organ function endpoints did not differ: incidence of acute kidney failure and sequential organ failure assessment score decrease were similar (-3.2 +/- 3.2 versus -4.2 +/- 2.3 over the course of 5 days). Plasma concentrations of selenium, zinc, and glutathione peroxidase, low on admission, increased significantly to within normal values in the AOX group. C-reactive protein decreased faster in the AOX group (P = 0.039). Infectious complications did not differ. Length of hospital stay did not differ (16.5 versus 20 days), being shorter only in surviving AOX trauma patients (-10 days; P = 0.045). CONCLUSION: The AOX intervention did not reduce early organ dysfunction but significantly reduced the inflammatory response in cardiac surgery and trauma patients, which may prove beneficial in conditions with an intense inflammation. TRIALS REGISTRATION: Clinical Trials.gov RCT Register: NCT00515736

Importation of Acinetobacter baumannii Into a Burn Unit: A Recurrent Outbreak of Infection Associated With Widespread Environmental Contamination

A burn patient was infected with Acinetobacter baumannii on transfer to the hospital after a terrorist attack. Two patients experienced cross-infection. Environmental swab samples were negative for A. baumannii. Six months later, the bacteria reemerged in 6 Patients. Environmental swab samples obtained at this time were inoculated into a minimal mineral broth, and culture results showed widespread contamination. No case of infection occurred after closure of the unit for disinfectio

Clinical nutrition issues in 2022: What is missing to trust supplemental parenteral nutrition (SPN) in ICU patients?

Clinical nutrition; Intensive care unit; Nutrition careNutrició clínica; Unitat de cures intensives; Cura de la nutricióNutrición Clínica; Unidad de cuidados intensivos; Cuidado de la nutriciónA multidisciplinary group of international physicians involved in the medical nutrition therapy (MNT) of adult critically ill patients met to discuss the value, role, and open questions regarding supplemental parenteral nutrition (SPN) along with oral or enteral nutrition (EN), particularly in the intensive care unit (ICU) setting. This manuscript summarizes the discussions and results to highlight the importance of SPN as part of a comprehensive approach to MNT in critically ill adults and for researchers to generate new evidence based on well-powered randomized controlled trials (RCTs). The experts agreed on several key points: SPN has shown clinical benefits, resulting in this strategy being included in American and European guidelines. Nevertheless, its use is heterogeneous across European countries, due to the persistence of uncertainties, such as the optimal timing and the risk of overfeeding in absence of indirect calorimetry (IC), which results in divergent opinions and barriers to SPN implementation. Education is also insufficient. The experts agreed on actions needed to increase evidence quality on SPN use in specific patients at a given time point during acute critical illness or recovery.The organization of the Virtual Meeting that motivated this publication was funded by Baxter Healthcare SA. The authors received no financial support for the research, authorship, and/or publication of this article. MPC receives funding from the Research Foundation Flanders (FWO) (Grant No. 1832817N) and Onderzoeksraad, KU Leuven (Grant No. C24/17/070) and from the Private Charity Organization “Help Brandwonden Kids

Perspective: Role of Micronutrients and Omega-3 Long-Chain Polyunsaturated Fatty Acids for Immune Outcomes of Relevance to Infections in Older Adults:A Narrative Review and Call for Action

The immune system is weakened by advancing age, often referred to as immunosenescence, increasing the vulnerability to, and frequently the severity of, infectious diseases in older people. This has become very apparent in the current coronavirus disease 2019 (COVID-19) pandemic for which older people are at higher risk of severe outcomes, even those who are fully vaccinated. Aging affects both the innate and adaptive immune systems and is characterized by an imbalanced inflammatory response. Increasing evidence shows that optimal status of nutrients such as vitamins C, D, and E and selenium and zinc as well as the omega-3 (n-3) fatty acids DHA and EPA can help compensate for these age-related changes. While inadequate intakes of these nutrients are widespread in the general population, this is often more pronounced in older people. Maintaining adequate intakes is a challenge for them due to a range of factors such as physical, physiological, and cognitive changes; altered absorption; and the presence of noncommunicable diseases. While nutritional requirements are ideally covered by a balanced diet, this can be difficult to achieve, particularly for older people. Fortified foods and nutritional complements are effective in achieving adequate micronutrient intakes and should be considered as a safe and cost-effective means for older people to improve their nutritional status and hence support their defense against infections. Complementing the diet with a combination of micronutrients, particularly those playing a key role in the immune system such as vitamins C, D, and E and selenium and zinc as well as DHA and EPA, is recommended for older people. Optimal nutrition to support the immune system in older people will remain essential, particularly in the face of the current COVID-19 pandemic and, thus, developing strategies to ensure adequate nutrition for the growing number of older adults will be an important and cost-effective investment in the future

Effects of endotoxin on lactate metabolism in humans.

ABSTRACT: INTRODUCTION: Hyperlactatemia represents one prominent component of the metabolic response to sepsis. In critically ill patients, hyperlactatemia is related to the severity of the underlying condition. Both an increased production and a decreased utilization and clearance might be involved in this process, but their relative contribution remains unknown. The present study aimed at assessing systemic and muscle lactate production and systemic lactate clearance in healthy human volunteers, using intravenous endotoxin (LPS) challenge. METHODS: Fourteen healthy male volunteers were enrolled in 2 consecutive studies (n = 6 in trial 1 and n = 8 in trial 2). Each subject took part in one of two investigation days (LPS-day with endotoxin injection and placebo-day with saline injection) separated by one week at least and in a random order. In trial 1, their muscle lactate metabolism was monitored using microdialysis. In trial 2, their systemic lactate metabolism was monitored by means of a constant infusion of exogenous lactate. Energy metabolism was monitored by indirect calorimetry and glucose kinetics was measured with 6,6-H2 glucose. RESULTS: In both trials, LPS increased energy expenditure (p = 0.011), lipid oxidation (p&lt;0.0001), and plasma lactate concentration (p = 0.016). In trial 1, lactate concentration in the muscle microdialysate was higher than in blood, indicating lactate production by muscles. This was, however, similar with and without LPS. In trial 2, calculated systemic lactate production increased after LPS (p = 0.031), while lactate clearance remained unchanged. CONCLUSIONS: LPS administration increases lactatemia by increasing lactate production rather than by decreasing lactate clearance. Muscle is, however, unlikely to be a major contributor to this increase in lactate production. TRIAL REGISTRATION: ClinicalTrials.gov NCT01647997

Reduction of nosocomial pneumonia after major burns by trace element supplementation: aggregation of two randomised trials

INTRODUCTION: Nosocomial pneumonia is a major source of morbidity and mortality after severe burns. Burned patients suffer trace element deficiencies and depressed antioxidant and immune defences. This study aimed at determining the effect of trace element supplementation on nosocomial or intensive care unit (ICU)-acquired pneumonia. METHODS: Two consecutive, randomised, double-blinded, supplementation studies including two homogeneous groups of 41 severely burned patients (20 placebo and 21 intervention) admitted to the burn centre of a university hospital were combined. Intervention consisted of intravenous trace element supplements (copper 2.5 to 3.1 mg/day, selenium 315 to 380 μg/day, and zinc 26.2 to 31.4 mg/day) for 8 to 21 days versus placebo. Endpoints were infections during the first 30 days (predefined criteria for pneumonia, bacteraemia, wound, urine, and other), wound healing, and length of ICU stay. Plasma and skin (study 2) concentrations of selenium and zinc were determined on days 3, 10, and 20. RESULTS: The patients, 42 ± 15 years old, were burned on 46% ± 19% of body surface: the combined characteristics of the patients did not differ between the groups. Plasma trace element concentrations and antioxidative capacity were significantly enhanced with normalisation of plasma selenium, zinc, and glutathione peroxidase concentrations in plasma and skin in the trace element-supplemented group. A significant reduction in number of infections was observed in the supplemented patients, which decreased from 3.5 ± 1.2 to 2.0 ± 1.0 episodes per patient in placebo group (p < 0.001). This was related to a reduction of nosocomial pneumonia, which occurred in 16 (80%) patients versus seven (33%) patients, respectively (p < 0.001), and of ventilator-associated pneumonia from 13 to six episodes, respectively (p = 0.023). CONCLUSION: Enhancing trace element status and antioxidant defences by selenium, zinc, and copper supplementation was associated with a decrease of nosocomial pneumonia in critically ill, severely burned patients