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Hervé Outin

Publications and source records attributed to Hervé Outin.

10 recordsLinked to original sources
PubMed2006

[Arousal disorders].

Altered states of consciousness are a common reason for visits to the emergency room and admission to intensive care unit. Management of unconscious patient can be difficult because the potential causes of an altered mental status are considerable and the time for diagnosis and effective intervention is short. First, the patient must airway, breathing, and circulation protected. It is important to obtain carefully taken history from eyewitnesses and to perform a general complete examination particularly neurologic focusing on pupillary responses, eye movements, and motor responses. Technical investigations like CT-scan and laboratory tests should make part of a careful diagnostic plan. The prognosis for recovery depends greatly on the underlying etiology as well as its optimal treatment, which seeks to preserve neurologic function and maximize the potential for recovery by reversing the primary cause of brain injury, if known, and preventing secondary brain injury from anoxia, ischemia, hypoglycemia, cerebral edema, and electrolyte disturbances.

Brain Diseases↗
PubMed2005

Sedation algorithm in critically ill patients without acute brain injury.

OBJECTIVE: To determine whether use of a sedation algorithm to promote a high level of tolerance to the intensive care environment and preserve consciousness affected time to arousal and duration of mechanical ventilation in patients without acute brain injury. DESIGN: Two-phase, prospective, controlled study. SETTING: University-affiliated medical intensive care unit. PATIENTS: : Patients without acute brain injury requiring mechanical ventilation for at least 24 hrs. INTERVENTIONS: During the control phase, sedatives and analgesics were adjusted according to the physician's decision. During the algorithm phase, sedatives and analgesics were adjusted according to an algorithm developed by a multidisciplinary team including nurses and physicians. The algorithm was based on regular assessments of consciousness and tolerance to the intensive care unit environment using the Adaptation to Intensive Care Environment instrument and was designed to achieve tolerance and maintain a high level of consciousness. Standard practices, including weaning from the ventilator, were the same during both study phases. MEASUREMENTS AND MAIN RESULTS: A total of 102 patients were enrolled (control group, n = 54; algorithm group, n = 48). Median duration of mechanical ventilation was significantly shorter in the algorithm group (4.4 days [interquartile range, 2.1-9.8]) compared with the control group (10.3 days [3.5-17.2], p = .014), representing a 57.3% reduction. In Cox multivariate analysis, the risk of remaining on mechanical ventilation was 0.48 times (95% confidence interval, 0.29-0.78) lower for algorithm patients compared with controls. The median time to arousal was also significantly shorter in patients in the algorithm group (2 days [2-5]) compared with the control group (4 days [2-9], p = .006). CONCLUSIONS: The use of a sedation algorithm to promote tolerance to the intensive care environment and preserve consciousness in patients without acute brain injury resulted in a marked decrease in the duration of mechanical ventilation. This reduction was at least partly attributable to a shorter time to arousal after initiation of mechanical ventilation.

Adult↗
PubMed2004

Does ICU-acquired paresis lengthen weaning from mechanical ventilation?

OBJECTIVE: To determine whether ICU-acquired paresis (ICUAP) is an independent risk factor of prolonged weaning. DESIGN: Second study of a prospective cohort of 95 patients who were enrolled in an incidence and risk factor study of ICUAP. SETTING: Three medical and two surgical ICUs in four hospitals. PATIENTS AND PARTICIPANTS: Ninety-five patients without pre-existing neuromuscular disease recovering from the acute phase of critical illness after > or =7 days of mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Duration of weaning from mechanical ventilation was defined as the duration of mechanical ventilation between awakening (day 1) and successful weaning. Muscle strength was evaluated at day 7 after awakening using the Medical Research Council (MRC) score. Patients with an MRC <48 were considered to have ICUAP. Among the 95 patients (mean age 62.0+/-15.3 years, SAPS 2 on admission 48.7+/-17.4) who regained satisfactory awakening after 7 or more days of mechanical ventilation, 67 (70.5%) were hospitalized in a medical ICU and 28 (29.5%) in a surgical ICU. Median duration (25th-75th percentiles) of weaning was longer in patients with ICUAP than in those without ICUAP: 6 days (1-22 days) vs 3 days (1-7 days); p=0.01; log-rank analysis. In multivariate analysis, the two independent predictors of prolonged weaning were ICUAP [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.4-4.2] and chronic obstructive pulmonary disease (HR: 2.7; 95% CI: 1.6-4.5) CONCLUSIONS: ICU-acquired paresis is an independent predictor of prolonged weaning. Prevention of ICU-acquired neuromuscular abnormalities in patients recovering from severe acute illness should result in shorter weaning duration.

Aged↗
PubMed2004

The effect of waiving consent on enrollment in a sepsis trial.

OBJECTIVE: Illustration of the difficulties in approaching critically ill patients for informed consent for inclusion into a randomized controlled trial and the impact of a waiver of consent from the patient's next of kin in the conduction of such studies. DESIGN: Descriptive survey of the inclusion rates into the Ger-Inf-05 study before and after a waiver of consent from the patient's next of kin. SETTING: Nineteen intensive care units in France. PATIENTS: Septic shock patients (n=300) included in a placebo-controlled randomized double-blind study on the efficacy and safety of a 7-day treatment with 50 mg hydrocortisone every 6 h intravenously and 50 microg fludrocortisone every 24 h orally. INTERVENTION: Introduction, 10 months after the beginning of the study, of a waiver of consent from the patient's next of kin if it was not present at the time of the patient's inclusion. MEASUREMENTS AND RESULTS: The mean inclusion rate was four patients per month before the introduction of the waiver of consent and increased to 10 patients per month after the study amendment including the waiver of consent. Informed consent was obtained from the patient himself or herself in 10 patients (3%) and from next of kin in 70 patients (23%). For the 220 other patients (74%), the investigators could not contact the responsible relative within the inclusion period. CONCLUSIONS: Recruitment rate in the Ger-Inf-05 study was clearly improved after the waiver of consent from the patient's next of kin. This probably contributed to the successful completion of the study.

Consent Forms↗
PubMed2004

Paresis following mechanical ventilation.

PURPOSE OF REVIEW: To review the medical literature on neuromuscular abnormalities acquired in the intensive care unit (ICU), particularly after mechanical ventilation, focusing on the most recent advances in this field. RECENT FINDING: Using a simple bedside muscle strength score, significant clinical weakness is detected in one fourth of patients awakening in ICU after more than 1 week of mechanical ventilation. Weakness is associated with a longer time on mechanical ventilation, although the exact relationship between limb and respiratory neuromuscular involvement remains unclear. Muscle involvement is often combined with axonal involvement and can predominate or occur in isolation in some patients. Although prolonged severe weakness is unusual, milder abnormalities may persist for several months after discharge. In addition to severity and duration of initial organ failures, both neuromuscular inactivity and use of corticosteroids make an independent contribution of the neuromuscular abnormalities. Conversely, strict glycemic control may prevent neuromuscular abnormalities, although this needs to be confirmed in general ICU patients. SUMMARY: Avoiding complete neuromuscular inactivity, using corticosteroids with greater discernment, and closely monitoring blood glucose levels might be worthwhile avenues for research in prevention of neuromuscular abnormalities acquired in the most severely ill ICU patients. Investigations of the severity of the respiratory neuromuscular involvement are also warranted.

Adrenal Cortex Hormones↗
PubMed2003

Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.

OBJECTIVE: To develop a valid, reliable, and responsive bedside instrument assessing Adaptation to the Intensive Care Environment (ATICE) in mechanically ventilated adult intensive care unit (ICU) patients. DESIGN: Instrument development and prospective clinimetric evaluation. SETTING: University-affiliated medical ICU. PATIENTS: Consecutive patients with expected mechanical ventilation of >/=12 hrs. INTERVENTIONS: Administration of ATICE. MEASUREMENTS AND MAIN RESULTS: Item generation for the ATICE involved focus groups and literature review. The ATICE consists of five items: Awakeness and Comprehension combined in a Consciousness domain, and Calmness, Ventilator Synchrony, and Face Relaxation combined in a Tolerance domain. Clinical sensibility of the ATICE assessed by ten ICU physicians and 20 ICU nurses not involved in the development of the ATICE was rated highly (median values 5-7 on a 7-point scale). The ATICE was administered to 80 patients during a total of 152 assessments. Each assessment was performed by three raters (ICU physician, ICU nurse, research nurse), concomitantly with independent scoring of four scales (Ramsay Scale, Riker Scale, Glasgow Coma Scale, and Comfort Scale) and six visual analog scales. Internal consistency was high, as reflected by Cronbach's alpha for the Consciousness and Tolerance domains of .87 and .67, respectively. Intraclass correlation coefficients for the Consciousness and the Tolerance domains ranged from .92 to .99, indicating high interrater reliability. Cross-sectional and longitudinal validity was confirmed for the overall ATICE and the Consciousness and Tolerance domains, as reflected by strong correlations between ATICE and the relevant items or domains of the Ramsay Scale, Riker Scale, Glasgow Coma Scale, Comfort Scale, each of the visual analog scales, and the amounts of sedatives and analgesics administered. CONCLUSIONS: The ATICE measures the adaptation of mechanically ventilated patients to the ICU environment. After rigorous multidisciplinary development, we demonstrated high reliability, validity, and responsiveness of this instrument.

Adaptation, Psychological↗
PubMed2002

Paresis acquired in the intensive care unit: a prospective multicenter study.

CONTEXT: Although electrophysiologic and histologic neuromuscular abnormalities are common in intensive care unit (ICU) patients, the clinical incidence of ICU-acquired neuromuscular disorders in patients recovering from severe illness remains unknown. OBJECTIVES: To assess the clinical incidence, risk factors, and outcomes of ICU-acquired paresis (ICUAP) during recovery from critical illness in the ICU and to determine the electrophysiologic and histologic patterns in patients with ICUAP. DESIGN: Prospective cohort study conducted from March 1999 to June 2000. SETTING: Three medical and 2 surgical ICUs in 4 hospitals in France. PARTICIPANTS: All consecutive ICU patients without preexisting neuromuscular disease who underwent mechanical ventilation for 7 or more days were screened daily for awakening. The first day a patient was considered awake was day 1. Patients with severe muscle weakness on day 7 were considered to have ICUAP. MAIN OUTCOME MEASURES: Incidence and duration of ICUAP, risk factors for ICUAP, and comparative duration of mechanical ventilation between ICUAP and control patients. RESULTS: Among the 95 patients who achieved satisfactory awakening, the incidence of ICUAP was 25.3% (95% confidence interval [CI], 16.9%-35.2%). All ICUAP patients had a sensorimotor axonopathy, and all patients who underwent a muscle biopsy had specific muscle involvement not related to nerve involvement. The median duration of ICUAP after day 1 was 21 days. Mean (SD) duration of mechanical ventilation after day 1 was significantly longer in patients with ICUAP compared with those without (18.2 [36.3] vs 7.6 [19.2] days; P =.03). Independent predictors of ICUAP were female sex (odds ratio [OR], 4.66; 95% CI, 1.19-18.30), the number of days with dysfunction of 2 or more organs (OR, 1.28; 95% CI, 1.11-1.49), duration of mechanical ventilation (OR, 1.10; 95% CI, 1.00-1.22), and administration of corticosteroids (OR, 14.90; 95% CI, 3.20-69.80) before day 1. CONCLUSIONS: Identified using simple bedside clinical criteria, ICUAP was frequent during recovery from critical illness and was associated with a prolonged duration of mechanical ventilation. Our findings suggest an important role of corticosteroids in the development of ICUAP.

Aged↗