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Biomedical subjects

Philippe Aegerter

Publications and source records attributed to Philippe Aegerter.

15 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

Breathing-swallowing interaction in neuromuscular patients: a physiological evaluation.

RATIONALE: Malnutrition and aspiration are major problems in patients with neuromuscular disease. Because impaired swallowing contributes to malnutrition, means of improving swallowing are needed. OBJECTIVES: To investigate interactions between breathing and swallowing in neuromuscular disorders and to evaluate the impact of mechanical ventilation (MV) on swallowing in tracheostomized patients. METHODS: We studied 10 healthy individuals and 29 patients with neuromuscular disease and chronic respiratory failure (including 19 with tracheostomy). The tracheostomized patients who could breathe spontaneously were recorded during spontaneous breathing (SB) and with MV, in random order. MEASUREMENTS AND MAIN RESULTS: Breathing-swallowing interactions were investigated by chin electromyography and inductive respiratory plethysmography, using three water-bolus sizes (5, 10, and 15 ml) in random order. In contrast to healthy individuals, neuromuscular patients showed piecemeal deglutition with several swallows over several breathing cycles for each bolus. The percentage of swallows followed by expiration was about 50% in the patients compared with nearly 100% in the control subjects. The number of swallows and total swallowing time per bolus correlated significantly to maximal inspiratory pressure. In the 10 tracheostomized patients who were recorded both in SB and MV, the number of swallows and total swallowing time per bolus were significantly reduced during MV compared with SB. CONCLUSION: Neuromuscular patients showed abnormal breathing-swallowing interactions, which correlated to maximal inspiratory pressure. Moreover, MV improved the swallowing parameters in tracheostomized patients who were able to breathe spontaneously.

Adolescent↗
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↗
PubMed2005

Early veno-venous haemodiafiltration for sepsis-related multiple organ failure.

INTRODUCTION: We conducted a prospective observational study from January 1995 to December 2004 to evaluate the impact on recovery of a major advance in renal replacement therapy, namely continuous veno-venous haemodiafiltration (CVVHDF), in patients with refractory septic shock. METHOD: CVVHDF was implemented after 6-12 hours of maximal haemodynamic support, and base excess monitoring was used to evaluate the improvement achieved. Of the 60 patients studied, 40 had improved metabolic acidosis after 12 hours of CVVHDF, with a progressive improvement in all failing organs; the final mortality rate in this subgroup was 30%. In contrast, metabolic acidosis did not improve in the remaining 20 patients after 12 hours of CVVHDF, and the mortality rate in this subgroup was 100%. The crude mortality rate for the whole group was 53%, which is significantly lower than the predicted mortality using Simplified Acute Physiology Score II (79%). CONCLUSION: Early CVVHDF may improve the prognosis of sepsis-related multiple organ failure. Failure to correct metabolic acidosis rapidly during the procedure was a strong predictor of mortality.

Acid-Base Imbalance↗
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

Management of bleeding peptic ulcer in France: a national inquiry.

AIMS OF THE STUDY: To evaluate and compare management practices in France for bleeding peptic ulcers using a national inquiry of university and non-university hospitals. METHOD: Responses to questionnaires sent to 812 gastroenterologists, 496 practicing in non-university hospitals and 316 in university hospitals, were compared. RESULTS: An analysis was possible in 279 (34% response rate) of the questionnaires. Forrest classification was used more frequently in university hospitals (83% vs 60%, P<0.01). Endoscopic hemostatic therapy was used more frequently in university hospitals for Forrest Ib (92% vs 81%, P=0.02), IIa (93% vs 73%, P<0.001), and IIb (58% vs 29%, P<0.001) ulcers. Injection therapy, mainly epinephrine, was the first-intention treatment for 99% of the responding gastroenterologists. Proportions of clinicians employing hemoclips (27%) or argon plasma coagulation (21%) were similar in both types of practice. Anti-secretory treatment included mainly omeprazole (82%), given intravenously (76%), sometimes as bolus i.v. doses followed by i.v. high-dose continuous infusion (15%) with some variations according to the type of hospital. In the event of recurrent or persistent bleeding, surgery was more frequent in non-university hospitals. When rebleeding occurred, a second endoscopic treatment was performed in about one quarter of patients. CONCLUSION: In France, management practices for bleeding peptic ulcer vary between university and non-university hospitals.

Endoscopy, Gastrointestinal↗
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

Analytical correlation between plasma N-terminal pro-brain natriuretic peptide and brain natriuretic peptide in patients presenting with dyspnea.

OBJECTIVES: We examined the analytical correlation N-terminal pro-brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP). DESIGN AND METHODS: Electrochemiluminescence and fluorescence immunoassays were used to measure NT-proBNP and BNP levels, respectively. RESULTS: The analytical correlation was satisfactory using the equation: NT-proBNP = 8.56 x BNP + 91.7 and a correlation r = 0.85. The correlation was not influenced by age, gender and BMI of patients. CONCLUSIONS: We conclude that NT-proBNP correlates with BNP.

Aged↗
PubMed2004

Benefits of obstructive sleep apnoea treatment in coronary artery disease: a long-term follow-up study.

AIM: The aim of this long-term prospective study was to evaluate the effect of treating obstructive sleep apnoea (OSA) on the rate of cardiovascular events in coronary artery disease (CAD). METHODS AND RESULTS: We prospectively studied 54 patients (mean age 57.3 +/- 10.1 years) with both CAD (> or = 70% coronary artery stenosis) and OSA (apnoea-hypopnoea index > or = 15). In 25 patients, OSA was treated with continuous positive airway pressure (n=21) or upper airway surgery (n=4); the remaining 29 patients declined treatment for their OSA. The median follow-up was 86.5 +/- 39 months. The two groups were similar at baseline in age, body mass index, smoking history, hypertension, hypercholesterolaemia, diabetes mellitus, number of diseased vessels, left ventricular ejection fraction, and CAD therapy. Treatment of risk factors other than OSA was similar in the two groups. The endpoint (a composite of cardiovascular death, acute coronary syndrome, hospitalisation for heart failure, or need for coronary revascularisation) was reached in 6 (6/25, 24%) and 17 (17/29, 58%) patients with and without OSA treatment, respectively (P<0.01). OSA treatment significantly reduced the risk of occurrence of the composite endpoint (hazard ratio 0.24; 95% confidence interval, 0.09-0.62; p<0.01) and of each of its components. CONCLUSIONS: Our data indicate that the treatment of OSA in CAD patients is associated with a decrease in the occurrence of new cardiovascular events, and an increase in the time to such events.

Body Mass Index↗
PubMed2003

Current epidemiology of septic shock: the CUB-Réa Network.

To update the epidemiology of septic shock we analyzed clinical, microbiologic, and outcome variables from 100,554 intensive care unit admissions on the Collège des Utilisateurs de Bases de données en Réanimation (CUB-Réa) database, collected from 22 hospitals over a 8-year period, 1993 to 2000. The overall frequency of septic shock was 8.2 per 100 admissions (i.e., 8,251 stays). It increased from 7.0 (in 1993) to 9.7 per 100 admissions (in 2000). The distribution analysis of the sites of infection and of the types of pathogens showed an increase in the rate of pulmonary infection (p = 0.001) and of multiresistant bacteria-related septic shock (p = 0.001). The crude mortality was 60.1% and declined from 62.1% (in 1993) to 55.9 (in 2000) (p = 0.001). As compared with matched intensive care unit admissions without sepsis, the excess risk of death due to septic shock was 25.7 (95% confidence interval, 24.0-27.3) and the matched odds ratio of death was 3.9 (95% confidence interval, 3.5-4.3). The frequency of septic shock is increasing with more multiresistant strains. Its crude mortality rate is decreasing, but patients with septic shock still have a high excess risk of death than critically ill patients who are nonseptic.

Comorbidity↗
PubMed2003

Low stretch ventilation strategy in acute respiratory distress syndrome: eight years of clinical experience in a single center.

CONTEXT: In recent years, protective ventilation with airway pressure limitation has constituted a major advance in acute respiratory distress syndrome treatment and has led to a substantial improvement in prognosis. With this therapeutic rationale, one may even question nowadays whether the severity of respiratory failure still influences mortality. OBJECTIVE: To determine whether the severity of respiratory failure, scored according to the usual criteria, still influences mortality in acute respiratory distress syndrome patients when a low stretch ventilation was used and to assess the impact on mortality of other nonpulmonary organ dysfunction, particularly circulatory failure. DESIGN AND SETTING: A retrospective study conducted in the medical intensive care unit of a French university hospital from October 1993 to December 2001. PATIENTS A total of 150 acute respiratory distress syndrome patients who were administered uniform protective ventilation with a limited plateau pressure (<30 cm H2O), a low positive end-expiratory pressure (<10 cm H2O), and the same strategy concerning hemodynamic support and dialysis when required. MAIN OUTCOME AND MEASURES: Mean age, general severity index (Simplified Acute Physiologic Score II), number of associated organ failures (Logistic Organ Dysfunction Score), respiratory severity indices (Pao2/Fio2, Lung Injury Severity Score), and severity of initial circulatory failure (circulatory failure present at admission or that developed during the first 48 hrs) were compared, according to recovery or death, and evaluated by a logistic regression model, which allows simultaneous control of multiple factors. RESULTS: The average mortality rate for the whole group was 38%, with 93 patients recovering after an average duration of mechanical ventilation of 18 +/- 13 days. The major factor significantly and independently associated with probability of dying was the severity of circulatory failure (p =.0001, odds ratio = 10.17). Patients free from initial circulatory failure (39 patients) had a 95% recovery rate. CONCLUSION: With our low stretch strategy, the severity of circulatory failure was the main determinant of acute respiratory distress syndrome prognosis. Patients with isolated respiratory failure during the first 48 hrs of respiratory support have an excellent chance of recovery when treated with protective ventilation associated with a low positive end-expiratory pressure.

APACHE↗
PubMed2002

Systemic candidiasis in intensive care units: a multicenter, matched-cohort study.

OBJECTIVE: To determine the impact of systemic candidiasis on the mortality and length of hospital stay of intensive care unit (ICU) patients and the associated workload. DESIGN: Multicenter, retrospective, matched-cohort study. SETTING: Data were retrieved from a computerized database that prospectively collected clinical data submitted by 32 ICUs in the Paris, France area. PATIENTS: A total of 149 stays with systemic candidiasis, including 104 candidemia, on ICU admission were identified in a 3-year period (1995-1997) among 49,063 admissions (3 per 1,000 admission). A total of 121 cases were matched with patients with no evidence of systemic Candida infection during the hospitalization period under study (same ICU, date of ICU admission, age, sex, simplified acute physiology score (SAPS II), location of the patient before admission, type of admission). RESULTS: Patients with systemic candidiasis had longer ICU length of stays than controls (25 vs 10 d; P =.001) with a relative risk for death of 2.27 (95% confidence interval, 1.64-3.11; P =.001). There was no difference between patients with systemic candidiasis with or without positive blood culture. CONCLUSIONS: Systemic Candida infections increased mortality and morbidity in severely ill patients. Optimizing management of such infections is imperative.

Candidiasis↗