The use of computerized echocardiographic simulation improves the learning curve for transesophageal hemodynamic assessment in critically ill patients

International audienceBackgroundOur aim was to evaluate the impact of a computerized echocardiographic simulator on the learning curve for transesophageal echocardiography (TEE) hemodynamic assessment of ventilated patients in the ICU.MethodsWe performed a prospective study in two university hospital medical ICUs. Using our previously validated skill assessment scoring system (/40 points), we compared learning curves obtained with (interventional group, n = 25 trainees) and without (control group, n = 31 trainees) use of a simulator in the training. Three evaluations were performed after 1 (M1), 3 (M3) and 6 months (M6) while performing two TEE examinations graded by an expert. Competency was defined as a score >35/40.ResultsCompetency was achieved after an average of 32.5 ± 10 supervised studies in the control group compared with only 13.6 ± 8.5 in the interventional group (p < 0.0001). At M6, a significant between-group difference in number of supervised TEE was observed (17 [14–28] in the control group vs. 30.5 [21.5–39.5] in the interventional group, p = 0.001). The score was significantly higher in the interventional group at M1 (32.5 [29.25–35.5] vs. 24.75 [20–30.25]; p = 0.0001), M3 (37 [33.5–38.5] vs. 32 [30.37–34.5]; p = 0.0004), but not at M6 (37.5 [33–39] vs. 36 [33.5–37.5] p = 0.24).ConclusionInclusion of echocardiographic simulator sessions in a standardized curriculum may improve the learning curve for hemodynamic evaluation of ventilated ICU patients

Impact of clinical guidelines to improve appropriateness of laboratory tests and chest radiographs.

International audienceOBJECTIVE: To assess the impact of clinical guidelines to improve appropriate use of routine laboratory tests and bedside chest radiographs in a medical intensive care. DESIGN: A two-year (Period-1: 2005, Period-2: 2006), retrospective, comparative study, before and after policy implementation. PATIENTS: All consecutive patients admitted during the study periods. SETTING: A university hospital 15-bed medical ICU. INTERVENTION: Multifaceted intervention combining a daily routine prescription help-guide developed by a multidisciplinary group and displayed at patient's bedside, educational sessions and feedbacks by information on volumes of prescription. Individual adaptation to patient's clinical status was allowed by protocol. ASSESSMENT: The overall number and cost of laboratory tests and chest radiographs during Period-2 (with the help guide; from 01 to 12-2006) were compared to Period-1 (from 01 to 12-2005). RESULTS: Patients' general characteristics were similar during the two periods. A relative reduction of routine laboratory tests performance was observed per patient-ICU-day, ranging from 38 to 71.5% depending on the type of tests (P < 0.001 in all cases). For chest radiographs, a 41% relative reduction was observed between the two periods (P < 0.001). Daily ICU laboratory tests and chest radiographs cost per patient decreased from 114 to 56 euros. An overall 300,000 euros ICU cost reduction was directly related to the protocol implementation. CONCLUSION: The implementation of a laboratory tests and chest radiographs prescription protocol within our ICU induced an important cost saving

Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial

International audienc

Cost-analysis of an intensive care unit closure due to an imipenem-resistant oxa-23 Acinetobacter baumannii outbreak.

International audienc

Investigation and management of an imipenem-resistant oxa-23 Acinetobacter baumannii outbreak in an intensive care unit. [Investigation et contrôle d'une épidémie d'Acinetobacter baumannii imipénème résistant oxa-23 dans un service de réanimation médicale.]

International audienceOBJECTIVES: The study objectives were to describe the investigation and management of an imipenem-resistant Acinetobacter baumannii outbreak that occurred in the 15-bed ICU of a tertiary care teaching hospital (Brest, France), during the summer 2008. PATIENTS AND METHODS: Patients harboring an imipenem-resistant A. baumannii strain were defined as case patients. We described case occurrence and steps taken to control the outbreak: contact isolation, reinforcement of hygiene procedures, unit shutdown decision, unit disinfection, and reopening. We also made a case control study and a cost analysis of the outbreak management. RESULTS: During a 10-day period, five patients were positive for a single clone of imipenem-resistant oxa-23 A. baumannii. Four patients presented with ventilation-acquired pneumonia and one was asymptomatic. The first two patients died one day after the first swab which led to the identification of A. baumannii. No additional case was noted in the ICU or in other hospital units after deciding to close the ICU. The cost of outbreak management was estimated at 264,553 euros. The case control study identified several factors associated with infection or colonization: length of stay in the ICU, chronic respiratory disease, number of previous antibiotic classes used, duration of ventilation, prone position, echocardiography, and presence of a nasogastric tube. CONCLUSION: This outbreak occurred during the summer period requiring the shutdown of the ICU and inducing a considerable cost. Rapid reactions of the ICU staff during the outbreak enabled to limit the epidemic

Outbreak of extended spectrum beta-lactamase-producing Klebsiella pneumoniae in an intensive care unit (Brest). [Épidémie à Klebsiella pneumoniae productrice de bêta-lactamase à spectre étendu dans deux services de réanimation (Brest)]

International audienceINTRODUCTION: We had for aim to describe control and investigation of an outbreak caused by a strain of Extended spectrum beta-lactamase producing Klebsiella pneumoniae in intensive care units of the Brest teaching hospital. PATIENTS AND METHOD: The case definition was a patient infected by or carrying the epidemic strain. Control measures and investigations are presented. A case-control study was conducted in the surgical intensive care unit. Each case was matched with two controls based on admission times in the unit. The study focused on diagnostic and therapeutic procedures, and potential contacts with healthcare workers, in this context of cross transmission. RESULTS: Between February and May 2011, nine cases were reported in the surgical ICU and two in the medical ICU. Eighteen controls were matched with the nine surgical ICU cases. Several factors were found to be statistically associated with infection or colonization by the epidemic strain: the surgical block in which patients had been operated and the ward of first hospitalization; the number of trans-esophageal and trans-thoracic echocardiographies, of central venous catheter insertions, and of surgical operations; intubation. The total number of invasive procedures was also found to be statistically higher among cases. CONCLUSION: This study identified factors associated with colonization or infection by the epidemic strain. These factors might have been involved in the transmission tree, and be vulnerable elements for the prevention of nosocomial infections and colonisations, and their epidemic spread

High-flow nasal oxygen therapy alone or with non-invasive ventilation in immunocompromised patients admitted to ICU for acute hypoxemic respiratory failure: the randomised multicentre controlled FLORALI-IM protocol

International audienc

Spontaneous-Breathing Trials with Pressure-Support Ventilation or a T-Piece

International audienceBackground: Spontaneous-breathing trials can be performed with the use of either pressure-support ventilation (PSV) or a T-piece. Whether PSV trials may result in a shorter time to tracheal extubation than T-piece trials, without resulting in a higher risk of reintubation, among patients who have a high risk of extubation failure is unknown.Methods: In this multicenter, open-label trial, we randomly assigned patients who had a high risk of extubation failure (i.e., were &gt;65 years of age or had an underlying chronic cardiac or respiratory disease) to undergo spontaneous-breathing trials performed with the use of either PSV (with a pressure-support level of 8 cm of water and no positive end-expiratory pressure) or a T-piece. The primary outcome was the total time without exposure to invasive ventilation (reported as the number of ventilator-free days) at day 28 after the initial spontaneous-breathing trial. Secondary outcomes included extubation within 24 hours and extubation within 7 days after the initial spontaneous-breathing trial, as well as reintubation within 7 days after extubation.Results: A total of 969 patients (484 in the PSV group and 485 in the T-piece group) were included in the analysis. At day 28, the median number of ventilator-free days was 27 (interquartile range, 24 to 27) in the PSV group and 27 (interquartile range, 23 to 27) in the T-piece group (difference, 0 days; 95% confidence interval [CI], -0.5 to 1; P = 0.31). Extubation was performed within 24 hours in 376 patients (77.7%) in the PSV group and in 350 patients (72.2%) in the T-piece group (difference, 5.5 percentage points; 95% CI, 0.01 to 10.9), and extubation was performed within 7 days in 473 patients (97.7%) and 458 patients (94.4%), respectively (difference, 3.3 percentage points; 95% CI, 0.8 to 5.9). Reintubation was performed in 72 of 481 patients (14.9%) in the PSV group and in 65 of 477 patients (13.6%) in the T-piece group (difference, 1.3 percentage points; 95% CI, -3.1 to 5.8). Cardiac or respiratory arrest was a reason for reintubation in 9 patients (3 in the PSV group and 6 in the T-piece group).Conclusions: Among patients who had a high risk of extubation failure, spontaneous-breathing trials performed with PSV did not result in significantly more ventilator-free days at day 28 than spontaneous-breathing trials performed with a T-piece. (Supported by the French Ministry of Health; TIP-EX ClinicalTrials.gov number, NCT04227639.)

Spontaneous-Breathing Trials with Pressure-Support Ventilation or a T-Piece

International audienceBackground: Spontaneous-breathing trials can be performed with the use of either pressure-support ventilation (PSV) or a T-piece. Whether PSV trials may result in a shorter time to tracheal extubation than T-piece trials, without resulting in a higher risk of reintubation, among patients who have a high risk of extubation failure is unknown.Methods: In this multicenter, open-label trial, we randomly assigned patients who had a high risk of extubation failure (i.e., were &gt;65 years of age or had an underlying chronic cardiac or respiratory disease) to undergo spontaneous-breathing trials performed with the use of either PSV (with a pressure-support level of 8 cm of water and no positive end-expiratory pressure) or a T-piece. The primary outcome was the total time without exposure to invasive ventilation (reported as the number of ventilator-free days) at day 28 after the initial spontaneous-breathing trial. Secondary outcomes included extubation within 24 hours and extubation within 7 days after the initial spontaneous-breathing trial, as well as reintubation within 7 days after extubation.Results: A total of 969 patients (484 in the PSV group and 485 in the T-piece group) were included in the analysis. At day 28, the median number of ventilator-free days was 27 (interquartile range, 24 to 27) in the PSV group and 27 (interquartile range, 23 to 27) in the T-piece group (difference, 0 days; 95% confidence interval [CI], -0.5 to 1; P = 0.31). Extubation was performed within 24 hours in 376 patients (77.7%) in the PSV group and in 350 patients (72.2%) in the T-piece group (difference, 5.5 percentage points; 95% CI, 0.01 to 10.9), and extubation was performed within 7 days in 473 patients (97.7%) and 458 patients (94.4%), respectively (difference, 3.3 percentage points; 95% CI, 0.8 to 5.9). Reintubation was performed in 72 of 481 patients (14.9%) in the PSV group and in 65 of 477 patients (13.6%) in the T-piece group (difference, 1.3 percentage points; 95% CI, -3.1 to 5.8). Cardiac or respiratory arrest was a reason for reintubation in 9 patients (3 in the PSV group and 6 in the T-piece group).Conclusions: Among patients who had a high risk of extubation failure, spontaneous-breathing trials performed with PSV did not result in significantly more ventilator-free days at day 28 than spontaneous-breathing trials performed with a T-piece. (Supported by the French Ministry of Health; TIP-EX ClinicalTrials.gov number, NCT04227639.)