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Biomedical subjects

Bertrand Guidet

Publications and source records attributed to Bertrand Guidet.

At least 19 recordsLinked to original sources
PubMed2007

Mortality among patients admitted to intensive care units during weekday day shifts compared with "off" hours.

OBJECTIVE: To determine whether mortality rates among intensive care unit (ICU) patients differ according to the time of ICU admission, we compared the death rates for patients admitted during weekday day shifts and off hours (from 6:30 pm to 8:29 am the next day for night shifts, from Saturday 1:00 pm to Monday 8:29 am for weekends, and from 8:30 am to 8:29 am the following morning for public holidays). METHODS: Retrospective cohort study of data collected prospectively from 23 ICUs located in the Paris metropolitan region, France. Between January 2000 and December 2003, 51,643 patients were admitted to these ICUs. Patients were grouped according to their day and time of admission and compared using univariable and multivariable analyses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 51,643 patients admitted to ICUs, 33,857 (65.6%) were admitted during off hours. These latter patients were less critically ill than those admitted during day shifts, had fewer failed organs, required fewer support procedures, and their crude in-hospital mortality was lower (20.7 vs. 24.5%, p < .0001). After adjustment for initial disease severity, in-hospital mortality was not higher for off-hours admissions than weekday day admissions and even remained slightly lower (adjusted odds ratio, 0.93; 95% confidence interval, 0.87-0.98). CONCLUSIONS: Admission during off hours is common. In our ICUs, off-hours admissions were not associated with higher mortality and might even be associated with a lower death rate.

APACHE↗
PubMed2006

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study.

OBJECTIVE: To assess on a multinational level the prevalence and corresponding factors of selected unintended events that compromise patient safety (sentinel events) in intensive care units (ICUs). DESIGN: An observational, 24-h cross-sectional study of incidents in five representative categories. SETTING: 205 ICUs worldwide MEASUREMENTS: Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed. RESULTS: In 1,913 adult patients a total of 584 events affecting 391 patients were reported. During 24 h multiple errors related to medication occurred in 136 patients; unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains in 158; equipment failure in 112; loss, obstruction or leakage of artificial airway in 47; and inappropriate turn-off of alarms in 17. Per 100 patient days, 38.8 (95% confidence interval 34.7-42.9) events were observed. In a multiple logistic regression with ICU as a random component, the following were associated with elevated odds for experiencing a sentinel event: any organ failure (odds ratio 1.13, 95% confidence interval 1.00-1.28), a higher intensity in level of care (odds ratio 1.62, 95% confidence interval 1.18-2.22), and time of exposure (odds ratio 1.06, 95% confidence interval 1.04-1.08). CONCLUSIONS: Sentinel events related to medication, indwelling lines, airway, and equipment failure in ICUs occur with considerable frequency. Although patient safety is recognised as a serious issue in many ICUs, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.

Adolescent↗
PubMed2006

Severe strongyloidiasis in corticosteroid-treated patients: case series and literature review.

OBJECTIVE: To describe the main features of severe strongyloidiasis in corticosteroid-treated patients METHODS: We report on 3 cases of corticosteroid-treated patients with severe strongyloidiasis and review cases of severe strongyloidiasis in corticosteroid-treated patients reported in the literature. RESULTS: One hundred and fifty-one cases of severe strongyloidiasis complicated a therapy with corticosteroids were evaluated. The mean age of the patients was 48+/-17 years and 71% were men. Corticosteroids were given for hematological malignancies in 34 (23%), systemic lupus erythematosus or vasculitis in 27 (18%), and nephropathy or renal transplantation in 32 (21%). At time of infection, the mean daily dosage of prednisone-equivalent was 52+/-42 mg (median: 40 mg) and 84% of patients had received a cumulative dosage of prednisone-equivalent higher than 1000 mg. The total duration of treatment ranged from 4 days to 20 years (6 months or less: 69%). Non-specific gastro-intestinal symptoms were reported in 91% of these patients associated or not with pulmonary complaints. Low-grade fever was present in 54% of patients. Fifty-nine patients (39%) experienced severe bacterial or yeast infection during the course of severe strongyloidiasis. Peripheral eosinophilia was detected at presentation in 32% of patients. Strongyloidiasis was usually confirmed by repeated stool examinations. Thiabendazole was the treatment the more widely used. Eighty-nine patients (59%) deceased during the course of the disease. CONCLUSIONS: Severe strongyloidiasis is a risk in every corticosteroid-treated patient who has traveled to a soil-infested country, even if the contact was 30 years prior. This diagnosis should be suspected in patients who either experience unusual gastro-intestinal or pulmonary symptoms or suffer from unexplained Gram-negative bacilli sepsis.

Adrenal Cortex Hormones↗
PubMed2006

Prophylactic low-molecular-weight heparin: prescription practice in an intensive care unit.

AIM: The aim of this study was to review the use of low-molecular-weight heparin (LMWH) in a medical intensive care unit. MATERIALS AND METHODS: Double-blind prospective study conducted in a 14-bed intensive care unit, covering all patients admitted over a 2-month period. A comparison with 2 guidelines based on indication, age of the patient, kidney function, platelet count, and duration of treatment was performed. Bleeding complication and clinically diagnosed phlebitis episodes were collected. RESULTS: One hundred thirty-six patients (71 treated with LMWH and 65 untreated) were included in the study (mean age, 60 +/- 18 years; SAPS (Simplified Acute Physiology Score) II, 39 +/- 23). Among treated patients, 9 were overtreated (13%), and among nontreated patients, 13 were undertreated (20%). In the cohort of treated patients, reasons for failure to comply with recommendations included age of the patient (30%), creatinine clearance (18%), platelet count (32.4%), and duration of treatment (12.7%). Low-molecular-weight heparin prescriptions were conforming to the 4 criteria in 35.2% of patients, to 3 in 43.7%, to 2 in 19.7%, and to 1 in 1.4%. CONCLUSION: The prescription of prophylactic LMWH in intensive care has become a routine. Our study shows that over- and underprescription are common together with misuse.

Adult↗
PubMed2006

Cost-effectiveness of drotrecogin alfa (activated) in the treatment of severe sepsis with multiple organ failure.

OBJECTIVES: The aim of this study was to estimate the expected cost and clinical benefits associated with the use of drotrecogin alfa (activated) (Xigris; Eli Lilly and Company; Indianapolis, IN) in the French hospital setting. METHODS: The recombinant human activated PROtein C Worldwide Evaluation in Severe Sepsis (PROWESS) study results (1271 patients with multiple organ failure) were adjusted to 9,948 hospital stays from a database of Parisian area intensive-care units (ICUs)-the CubRea (Intensive Care Database User Group) database. The analysis features a decision tree with a probabilistic sensitivity analysis. RESULTS: The cost per life year gained (LYG) of drotrecogin treatment for severe sepsis with multiple organ failure (European indication) was estimated to be dollars 11,812. At the hospital level, the drug is expected to induce an additional cost of dollars 7545 per treated patient. The incremental cost-effectiveness ratio ranges from dollars 7873 per LYG for patients receiving three organ supports during ICU stay to dollars 17,704 per LYG for patients receiving less than two organ supports. CONCLUSIONS: Drotrecogin alfa (activated) is cost-effective in the treatment of severe sepsis with multiple organ failure when added to best standard care. The cost-effectiveness of the drug increases with baseline disease severity, but it remains cost-effective for all patients when used in compliance with the European approved indication.

Acute Disease↗
PubMed2006

Renal cortical necrosis related to paraneoplastic antiphospholipid syndrome.

Acute bilateral renal cortical necrosis is a very rare cause of acute renal failure. We report here for the first time a case related to antiphospholipid syndrome, paraneoplastic of a lung neoplasia. A 46-year-old male smoker without medical history was admitted for acute dyspnea and anuria. Biological examination showed acute renal failure associated with hyperkalemia, high serum lactate dehydrogenase level, and prolonged activated thrombin time (ratio 1.29). Chest radiograph showed a right laterotracheal round lesion. A percutaneous left renal biopsy showed cortical necrosis, and renal arteriography confirmed bilateral cortical necrosis. Blood examination showed antiphospholipid antibodies type anticardiolipin. Chest computed tomographic scan confirmed the presence of a lung tumor. Two years after tumor surgery, the patient was still anuric and on long-term hemodialysis therapy, but antiphospholipid antibody results were negative. This case describes the first association of antiphospholipid syndrome to epidermoid lung cancer, shown by cortical bilateral necrosis. It also emphasizes the utility of renal biopsy in case of an unusual acute renal failure.

Acute Kidney Injury↗
PubMed2005

Sonography as an alternative to radiography for nasogastric feeding tube location.

OBJECTIVE: To evaluate bedside sonographic confirmation of weighted-tip nasogastric feeding tube position, by comparison to radiography. DESIGN AND SETTING: Single-center, double-blind prospective study in a 14-bed medical intensive care unit (ICU) in a 780-bed teaching hospital. PATIENTS: Thirty-three ICU patients undergoing nasogastric tube insertion for enteral feeding. INTERVENTIONS: The tip of the nasogastric tube was located both by sonography and standard radiography. MEASUREMENTS AND RESULTS: The accuracy and procedure times of sonography and radiography for nasogastric tube tip location were compared during 35 procedures in 33 patients. The nasogastric tube tip was visualized by sonography in 34 of 35 procedures (sensitivity 97%) and by radiography in all procedures. The median length of the entire procedure was 24 min and 180 min with sonography and radiography, respectively. CONCLUSIONS: Bedside sonography performed by nonradiologists is a sensitive method for confirming the position of weighted-tip feeding nasogastric feeding tubes. It is more rapid than conventional radiography and can easily be taught to ICU physicians. Conventional radiography could be reserved for cases in which sonography is inconclusive.

Double-Blind Method↗
PubMed2005

SAPS II revisited.

OBJECTIVE: To construct and validate an update of the Simplified Acute Physiology Score II (SAPS II) for the evaluation of clinical performance of Intensive Care Units (ICU). DESIGN AND SETTING: Retrospective analysis of prospectively collected multicenter data in 32 ICUs located in the Paris area belonging to the Cub-Rea database and participating in a performance evaluation project. PATIENTS: 33,471 patients treated between 1999 and 2000. MEASUREMENTS AND RESULTS: Two logistic regression models based on SAPS II were developed to estimate in-hospital mortality among ICU patients. The second model comprised reevaluation of original items of SAPS II and integration of the preadmission location and chronic comorbidity. Internal and external validation were performed. In the two validation samples the most complex model had better calibration than the original SAPS II for in-hospital mortality but its discrimination was not significantly higher (area under ROC curve 0.89 vs. 0.87 for SAPS II). Second-level customization and integration of new items improved uniformity of fit for various categories of patients except for diagnosis-related groups. The rank order of ICUs was modified according to the model used. CONCLUSIONS: The overall performance of SAPS II derived models was good, even in the context of a community cohort and routinely gathered data. However, one-half the variation of outcome remains unexplained after controlling for admission characteristics, and uniformity of prediction across diagnostic subgroups was not achieved. Differences in case-mix still limit comparisons of quality of care.

APACHE↗
PubMed2005

Culture, organization, and management in intensive care: construction and validation of a multidimensional questionnaire.

OBJECTIVE: The objective of this study is to develop and validate a questionnaire designed to assess the culture, organization, and management of intensive care units. DESIGN: This is a prospective multicenter study. SETTING: The study was conducted in 26 intensive care units located in Paris. PARTICIPANTS: All personnel were asked to complete the questionnaire. INTERVENTION: The questionnaire was developed in 2 steps: (1) development of a theoretical framework based on organizational theory and (2) testing of the reliability and validity of a comprehensive set of measures. METHOD: The internal consistency of the items composing each scale was tested by using the Cronbach alpha. Convergent, and discriminant validity was assessed by factor analysis with varimax rotation. RESULTS: The overall completion rate was 74% with 1000 respondents (750 nurses, 26 head nurses, 168 physicians, and 56 medical secretaries). Starting with a 220-item questionnaire, we constructed a short version-conserving metrological characteristics with good reliability and validity. The short questionnaire, entitled Culture, Organization, and Management in Intensive Care, consists of 106 items distributed in 9 dimensions and 22 scales: culture (n = 3), coordination and adaptation to uncertainty (n = 3), communication (n = 3), problem solving and conflict management (n = 2), organizational learning and organizational change (n = 2), skills developed in a patient-caregiver relationship (n = 1), subjective unit performance (n = 3), burnout (n = 3), and job satisfaction and intention to quit (n = 2). All the scales showed good-to-high reliability, with Cronbach alpha scores higher than .7 (with the exception of coordination [.6]). Team satisfaction-oriented culture is positively correlated with good managerial practices and individual well-being. CONCLUSIONS: The Culture, Organization, and Management in Intensive Care questionnaire enables staff and managers to assess the organizational performance of their intensive care unit.

Attitude of Health Personnel↗
PubMed2005

Treatment intensity and outcome of patients aged 80 and older in intensive care units: a multicenter matched-cohort study.

OBJECTIVES: To determine whether patients aged 80 and older have similar treatment intensity to that of younger patients in the intensive care unit (ICU). DESIGN: Multicenter, matched-cohort study. SETTING: Data were extracted from a multicenter database with 36 ICUs in the Paris area (France) during a 4-year period (1997-2000). PARTICIPANTS: Three thousand one hundred seventy-five patients aged 80 and older (oldest-old) were retrospectively matched to 3,175 patients aged 65 to 79 (young-old). MEASUREMENTS: The matching criteria were severity status on admission (+/-2) (assessed using a corrected Simplified Acute Physiology Score II leaving out age points), Charlson Comorbidity Index, type of admission (surgical vs medical), sex, admission to same ICU, and year of ICU admission. The underlying condition was classified using the McCabe classification. The functional status was assessed using the Knaus classification. The ICU workload was assessed using the OMEGA scoring system. RESULTS: Total and daily workload were lower in the oldest-old than in matched young-old patients. Estimated mean direct medical cost per stay was approximately 1,280 dollars lower for oldest-old patients. Older patients received less mechanical ventilation (adjusted odds ratio (AOR)=0.69, 95% confidence interval (CI)=0.61-0.78), less tracheostomy (AOR=0.37, 95% CI=0.28-0.50), and less renal support (AOR=0.52, 95% CI=0.41-0.66) than matched young-old patients. Oldest-old patients had a shorter length of ICU stay than matched young-old patients and the same length of post-ICU stay. CONCLUSION: Oldest-old patients receive less treatment in the ICU than young-old patients even after adjustment for severity of illness.

Aged↗
PubMed2005

Incidence and impact of organ dysfunctions associated with sepsis.

OBJECTIVE: To study the incidence and severity of organ dysfunction associated with sepsis. DESIGN: Comprehensive review of prospectively collected data from intensive care patients hospitalized between 1997 and 2001. SETTING: Thirty-five ICUs in nonuniversity and university hospitals located in the Paris area. PATIENTS: All patients hospitalized in the ICU for > 24 h meeting the criteria for severe sepsis (SS), either with only one organ dysfunction present during the ICU stay (SS1; n = 5,675) or with at least two organ dysfunction present during the ICU stay (SS2; n = 12,598), were compared to all other patients hospitalized for > 24 h in the ICU over the same time period (n = 47,637). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We collected information on demographic characteristics, type of admission, underlying disease, organ dysfunction, organ support, McCabe and Charlson-Deyo scores, simplified acute physiology score II, length of stay, and outcome. The incidence of SS was 27.7% (8.6% for SS1 and 19.1 for SS2). Compared with non-SS patients, those with SS were significantly older, were more frequently men, required organ support more frequently, had higher severity scores, and stayed longer in the ICU and hospital. Respiratory and cardiovascular dysfunction and fungal infection were strong independent risk factors for death in SS patients, with 5.64-fold, 4.35-fold, and 2.0-fold increased risks, respectively. SS2 is significantly different from SS1: older age, more surgical stays and admission from external transfer, greater number of organ supports, site of infection (less pulmonary and urinary tract infections, and more abdominal and cardiovascular infections), type of bacteria (more methicillin-resistant Staphylococcus aureus, Pseudomonas, and fungus), ICU length of stay (20.4 d vs 11.6 d), hospital length of stay (33 d vs 27.9 d), ICU mortality (42.7% vs 5.5%), and hospital mortality (49% vs 11.3%). CONCLUSIONS: Our study identifies a subgroup of patients with an ICU stay > 24 h and SS with at least two organ dysfunctions. This group of patients requires special attention since their ICU mortality is > 40% and they occupy almost 40% of all ICU beds.

APACHE↗
PubMed2004

Prognosis of patients aged 80 years and over admitted in medical intensive care unit.

OBJECTIVE: To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over. DESIGN. Prospective cohort study. SETTING: A 14-bed MICU in a 970-bed, acute care, tertiary, university hospital in Paris, France. PATIENTS: A total of 233 patients aged 80 years and over discharged from a MICU during a 2-year period. MEASUREMENTS AND MAIN RESULTS: Severity at admission was estimated using the Simplified Acute Physiology Score. The underlying condition was classified using the MacCabe classification. The functional status was assessed using the Knaus classification. The outcome after MICU discharge was determined after a median 2-year follow-up. The functional outcome was assessed by telephone interviews, employing the Instrumental Activities of Daily Living (IADL). The in-MICU mortality was 19.5% including death occurring during the 2 days following discharge. The long-term survival rates for patients admitted to the MICU were 59% at 2 months, 33% at 2 years, and 29% at 3 years. The multivariate analysis identified two prognostic factors of death after discharge: presence of an underlying fatal disease (HR 1.7; 95% CI 1.1-2.6) and severe functional limitation (HR 1.7; 95% CI 1.2-2.6). The IADL was excellent or good for 56% of the surviving patients. CONCLUSION: Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.

Aged↗
PubMed2004

How to identify patients with no risk for postextubation stridor?

The aim of this study was first, to evaluate the value of cough following tracheal tube cuff deflation, and second, to reassess the value of the cuff-leak test to predict postextubation stridor (PES). In spontaneously breathing patients, immediately before extubation, the tracheal tube was deflated and the absence of cough was monitored. The tube was then obstructed with a finger, and the absence of leak was monitored. Extubation was then performed. Four PESs were observed after 115 extubations (incidence: 3.5%). The absence of cough was more frequently observed when PES occurred than when it did not (75% v 21%, P =.04). The absence of leak was observed in 100% of PES and in 20% of PES free extubations (P =.01). The absence of both leak and cough was more frequently observed in PES (75% v 7%, P <.0001). In the absence of leak, the likelihood ratio of developing PES was 5.04 and rose to 10.4 when cough was also absent. The likelihood ratio of not developing PES in the absence of leak alone was 0. We conclude that in a population of medical intensive care unit spontaneously breathing patients, just before extubation, the presence of leaking around the endotracheal tube rules out PES, whereas the absence of cough and of leak are good predictors of PES.

Adult↗