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Search Results: 1 - 10 of 5231 matches for " Bernard Allaouchiche "
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Impact of surveillance of hospital-acquired infections on the incidence of ventilator-associated pneumonia in intensive care units: a quasi-experimental study
Thomas Bénet, Bernard Allaouchiche, Laurent Argaud, Philippe Vanhems
Critical Care , 2012, DOI: 10.1186/cc11484
Abstract: A quasi-experimental study with an intervention group and a control group was conducted between 1 January 2004 and 31 December 2010 in two intensive care units (ICUs) of a university hospital that participated in a national HAI surveillance network. Surveillance was interrupted during the year 2007 in unit A (intervention group) and was continuous in unit B (control group). Period 1 (pre-test period) comprised patients hospitalized during 2004 to 2006, and period 2 (post-test period) involved patients hospitalized during 2008 to 2010. Patients hospitalized ≥48 hours and intubated during their stay were included. Multivariate Poisson regression was fitted to ascertain the influence of surveillance disruption.A total of 2,771 patients, accounting for 19,848 intubation-days at risk, were studied; 307 had VAP. The VAP attack rate increased in unit A from 7.8% during period 1 to 17.1% during period 2 (P <0.001); in unit B, it was 7.2% and 11.2% for the two periods respectively (P = 0.17). Adjusted VAP incidence rose in unit A after surveillance disruption (incidence rate ratio = 2.17, 95% confidence interval 1.05 to 4.47, P = 0.036), independently of VAP trend; no change was observed in unit B. All-cause mortality and length of stay increased (P = 0.028 and P = 0.038, respectively) in unit A between periods 1 and 2. In unit B, no change in mortality was observed (P = 0.22), while length of stay decreased between periods 1 and 2 (P = 0.002).VAP incidence, length of stay and all-cause mortality rose after HAI surveillance disruption in ICU, which suggests a specific effect of HAI surveillance on VAP prevention and reinforces the role of data feedback and counselling as a mechanism to facilitate performance improvement.Ventilator-associated pneumonia (VAP) is a major concern in intensive care units (ICUs) because of its high incidence and related mortality [1]. In the French national surveillance system of hospital-acquired infections (HAIs) in ICUs, 12.4% of intubated pati
CD4+ T-lymphocyte alterations in trauma patients
Aurélie Gouel-Chéron, Fabienne Venet, Bernard Allaouchiche, Guillaume Monneret
Critical Care , 2012, DOI: 10.1186/cc11376
Abstract: In parallel with a study recently published in Critical Care in which mHLA-DR expression was assessed [2], we evaluated the CD4+ lymphocyte count and the percentage of CD4+CD25+ regulatory T cells in trauma patients. Sixty-five patients were included (mean ± standard deviation): age 41 ± 18 years, Simplified Acute Physiology Score II 45 ± 16, and Injury Severity Score 38 ± 10. Of these patients, 21 developed sepsis (mainly pneumonia - median delay 4 days) and two died of septic shock. Importantly, 3 days after trauma the patients presented with significant CD4+ lymphocyte alterations: a significantly decreased CD4+ T-cell count and an increased regulatory T-cell percentage (versus control values, P <0.0001; Table 1). Interestingly, we observed a trend toward lower CD4+ T-cell values in patients presenting with secondary infections versus non-infected individuals (343 cells/μl vs. 454 cells/μl, respectively).Our results reinforce the observations made by Heffernan and colleagues [1]. We confirm here that trauma patients exhibit CD4+ T-cell loss with a relative increase in regulatory T-cell values - both parameters associated with unfavourable outcomes after septic shock [3]. Collectively, these data suggest that, in addition to monocyte anergy [2], lymphocyte alterations should be taken into account in the monitoring of trauma patients. Lymphocyte subset counts and phenotyping deserve to be investigated in large cohorts of trauma patients to minutely delineate association with specific clinical outcomes.mHLA-DR: monocytic Human Leukocyte Antigen DR.The authors declare that they have no competing interests.
Early Interleukin-6 and Slope of Monocyte Human Leukocyte Antigen-DR: A Powerful Association to Predict the Development of Sepsis after Major Trauma
Aurélie Gouel-Chéron, Bernard Allaouchiche, Caroline Guignant, Fanny Davin, Bernard Floccard, Guillaume Monneret, for AzuRea Group
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0033095
Abstract: Objective Major trauma is characterized by a pro-inflammatory response, followed by an immunosuppression. Recently, in trauma patients, the lack of recovery of monocyte Human Leukocyte Antigen DR (mHLA-DR, a biomarker of ICU-acquired immunosuppression) between days 1–2 and days 3–4 has been demonstrated to be independently associated with sepsis development. The main objective of this study was to determine whether early measurements of IL-6 (interleukin-6) and IL-10 plasma concentrations (as markers of initial severity) could improve, in association with mHLA-DR recovery, the prediction of sepsis occurrence in severe trauma patients. Design Prospective observational study over 24 months in a Trauma ICU at university hospital. Patients Trauma patients with an ISS over 25 and age over 18 were included. Measurements and Main Results mHLA-DR was assessed by flow cytometry, IL-6 and IL-10 concentrations by ELISA. 100 consecutive severely injured patients were monitored (mean ISS 37±10). 37 patients developed sepsis. IL-6 concentrations and slope of mHLA-DR expression between days 1–2 and days 3–4 were significantly different between septic and non-septic patients. IL-10 was not detectable in most patients. After adjustment for usual clinical confounders, when assessed as a pair, multivariate logistic regression analysis revealed that a slope of mHLA-DR expression (days 3–4/days 1–2)≤1.1 and a IL-6 concentration ≥ 67.1 pg/ml remained highly associated with the development of sepsis (adjusted OR 18.4, 95% CI 4.9; 69.4, p = .00002). Conclusions After multivariate regression logistic analysis, when assessed as a pair, a high IL-6 concentration and a persistent mHLA-DR decreased expression were found to be in relation with the development of sepsis with the best predictive value. This study underlines the usefulness of daily monitoring of immune function to identify trauma patients at a high risk of infection.
Lack of recovery in monocyte human leukocyte antigen-DR expression is independently associated with the development of sepsis after major trauma
Aurélie Cheron, Bernard Floccard, Bernard Allaouchiche, Caroline Guignant, Fran?oise Poitevin, Christophe Malcus, Jullien Crozon, Alexandre Faure, Christian Guillaume, Guillaume Marcotte, Alexandre Vulliez, Olivier Monneuse, Guillaume Monneret
Critical Care , 2010, DOI: 10.1186/cc9331
Abstract: We conducted a prospective observational study over 23 months in a trauma intensive care unit at a university hospital. Patients with an Injury Severity Score (ISS) over 25 and age over 18 were included. mHLA-DR was assessed by flow cytometry protocol according to standardized protocol. Mann-Whitney U-test for continuous non-parametric variables, independent paired t test for continuous parametric variables and chi-square test for categorical data were used.mHLA-DR was measured three times a week during the first 14 days. One hundred five consecutive severely injured patients were monitored (ISS 38 ± 17, SAPS II 37 ± 16). Thirty-seven patients (35%) developed sepsis over the 14 days post-trauma. At days 1-2, mHLA-DR was diminished in the whole patient population, with no difference with the development of sepsis. At days 3-4, a highly significant difference appeared between septic and non-septic patients. Non- septic patients showed an increase in mHLA-DR levels, whereas septic patients did not (13,723 ± 7,766 versus 9,271 ± 6,029 antibodies per cell, p = .004). Most importantly, multivariate logistic regression analysis, after adjustment for usual clinical confounders (adjusted OR 5.41, 95% CI 1.42-20.52), revealed that a slope of mHLA-DR expression between days1-2 and days 3-4 below 1.2 remained associated with the development of sepsis.Major trauma induced an immunosuppression, characterized by a decrease in mHLA-DR expression. Importantly, after multivariate regression logistic analysis, persistent decreased expression was assessed to be in relation with the development of sepsis. This is the first study in trauma patients showing a link between the lack of immune recovery and the development of sepsis on the basis of the standardized protocol. Monitoring immune function by mHLA-DR measurement could be useful to identify trauma patients at a high risk of infection.The global burden of death and disability due to injuries is increasing, especially in patients you
The Practice of Therapeutic Hypothermia after Cardiac Arrest in France: A National Survey
Jean-Christophe Orban, Florian Cattet, Jean-Yves Lefrant, Marc Leone, Samir Jaber, Jean-Michel Constantin, Bernard Allaouchiche, Carole Ichai, for the AzuRéa group
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0045284
Abstract: Aims Cardiac arrest is a major health concern worldwide accounting for 375,000 cases per year in Europe with a survival rate of <10%. Therapeutic hypothermia has been shown to improve patients’ neurological outcome and is recommended by scientific societies. Despite these guidelines, different surveys report a heterogeneous application of this treatment. The aim of the present study was to evaluate the clinical practice of therapeutic hypothermia in cardiac arrest patients. Methods This self-declarative web based survey was proposed to all registered French adult intensive care units (ICUs) (n = 357). Paediatrics and neurosurgery ICUs were excluded. The different questions addressed the structure, the practical modalities of therapeutic hypothermia and the use of prognostic factors in patients admitted after cardiac arrest. Results One hundred and thirty-two out of 357 ICUs (37%) answered the questionnaire. Adherence to recommendations regarding the targeted temperature and hypothermia duration were 98% and 94% respectively. Both guidelines were followed in 92% ICUs. During therapeutic hypothermia, sedative drugs were given in 99% ICUs, mostly midazolam (77%) and sufentanil (59%). Neuromuscular blocking agents (NMBA) were used in 97% ICUs, mainly cisatracurium (77%). Numerous prognostic factors were used after cardiac arrest such as clinical factors (95%), biomarkers (53%), electroencephalography (78%) and evoked potentials (35%). Conclusions In France, adherence to recommendations for therapeutic hypothermia after cardiac arrest is higher than those previously reported in other countries. Numerous prognostic factors are widely used even if their reliability remains controversial.
Early-onset ventilator-associated pneumonia incidence in intensive care units: a surveillance-based study
Philippe Vanhems, Thomas Bénet, Nicolas Voirin, Jean-Marie Januel, Alain Lepape, Bernard Allaouchiche, Laurent Argaud, Dominique Chassard, Claude Guérin, the Study Group
BMC Infectious Diseases , 2011, DOI: 10.1186/1471-2334-11-236
Abstract: We analyzed data from prospective surveillance between 01/01/2001 and 31/12/2009 in 11 ICUs of Lyon hospitals (France). The inclusion criteria were: first ICU admission, not hospitalized before admission, invasive mechanical ventilation during first ICU day, free of antibiotics at admission, and ICU stay ≥ 48 hours. VAP was defined according to a national protocol. Its incidence was the number of events per 1,000 invasive mechanical ventilation-days. The Poisson regression model was fitted from day 2 (D2) to D8 to incident VAP to estimate the expected VAP incidence from D0 to D1 of ICU stay.Totally, 367 (10.8%) of 3,387 patients in 45,760 patient-days developed VAP within the first 9 days. The predicted cumulative VAP incidence at D0 and D1 was 5.3 (2.6-9.8) and 8.3 (6.1-11.1), respectively. The predicted cumulative VAP incidence was 23.0 (20.8-25.3) at D8. The proportion of missed VAP within 48 hours from admission was 11% (9%-17%).Our study indicates underestimation of early-onset VAP incidence in ICUs, if only VAP occurring ≥ 48 hours are considered to be hospital-acquired. Clinicians should be encouraged to develop a strategy for early detection after ICU admission.The epidemiological surveillance of healthcare-associated infections (HAIs) in intensive care units (ICUs) provides clinicians and caregivers with trend descriptions and contributes to HAI prevention [1-4]. When studies from such epidemiological surveillance programs are carried out, standardized definitions of risk factors for HAI must be used. However, these distinctions as well as the terminology adopted change over time. Indeed, in the last Centers for Disease Control and Prevention definition, HAI replaced the term "hospital-acquired infection" [5].To exclude community-acquired infections, it was acknowledged that a period of 48 hours between ICU admission and the onset of symptoms was required to identify cases as hospital-acquired infections [1-4,6-10]. The time window of 48 hours was first con
Fluid management and risk factors for renal dysfunction in patients with severe sepsis and/or septic shock
Laurent Muller, Samir Jaber, Nicolas Molinari, Laurent Favier, Jér?me Larché, Gilles Motte, Sonia Lazarovici, Luc Jacques, Sandrine Alonso, Marc Leone, Jean Constantin, Bernard Allaouchiche, Carey Suehs, Jean-Yves Lefrant, the AzuRéa Group
Critical Care , 2012, DOI: 10.1186/cc11213
Abstract: Among the 435 patients in a multicenter study of patients with severe sepsis and septic shock in 15 Southern French ICUs, 388 patients surviving after 24 hour, without a history of renal failure were included. Factors associated with renal dysfunction and RRT were isolated using a multivariate analysis with logistic regression.Renal dysfunction was reported in 117 (33%) patients. Ninety patients required RRT. Among study participants, 379 (98%) were administered fluids in the first 24 hours of management: HES 130/0.4 only (n = 39), crystalloids only (n = 63), or both HES 130/0.4 and crystalloids (n = 276). RRT was independently associated with the need for vasopressors and the baseline value of serum creatinine in the first 24 hours. Multivariate analysis indicated that male gender, SAPS II score, being a surgical patient, lack of decrease in SOFA score during the first 24 hours, and the interventional period of the study were independently associated with renal dysfunction. Mortality increased in the presence of renal dysfunction (48% versus 24%, P < 0.01).Despite being used in more than 80% of patients with severe sepsis and/or septic shock, the administration of HES 130/0.4 in the first 24 hours of management was not associated with the occurrence of renal dysfunction.In patients with severe sepsis and septic shock, acute renal failure (ARF) is an independent factor for mortality [1,2]. In the last decade, significant efforts were made to standardize the treatment of septic shock [3,4]. One of the most important recommendations is volume expansion that could also prevent ARF [5,6]. However, the type of fluid, especially the use of colloids, for volume expansion in septic shock remains a matter of debate [7-11]. Indeed, despite a larger plasma volume expansion power [12-14], the use of hydroxyethylstarch (HES) is not related to better outcomes when compared to isotonic crystalloids. In addition, use of HES has been associated with the development of an impaired re
How the relationships between general practitioners and intensivists can be improved: the general practitioners' point of view
Bérengère Etesse, Samir Jaber, Thibault Mura, Marc Leone, Jean-Michel Constantin, Pierre Michelet, Lana Zoric, Xavier Capdevila, Fran?ois Malavielle, Bernard Allaouchiche, Jean-Christophe Orban, Pascale Fabbro-Peray, Jean-Yves Lefrant, the AzuRéa Group
Critical Care , 2010, DOI: 10.1186/cc9061
Abstract: An anonymous questionnaire was mailed to 7,239 GPs. GPs were asked about their professional activities, postgraduate intensive care unit (ICU) training, the rate of patient admittance to ICUs, and their relationships with intensivists. Relationship assessment was performed by using a graduated visual analogue scale (VAS) ranging from 0 (dissatisfaction) to 100 (satisfaction). A multivariate analysis with stepwise logistic regression was performed to isolate factors explaining dissatisfaction (VAS score, < 25th percentile).Twenty-two percent of the GPs (1,561) responded. The median satisfaction score was 57 of 100 (interquartile (IQ), 35 to 77]. Five independent factors of dissatisfaction were identified: no information provided to GPs at patient admission (odds ratio (OR) = 2.55 (1.71 to 3.80)); poor quality of family reception in the ICU (OR = 2.06 (1.40 to 3.02)); the ICU's family contact person's identity or function or both is unclear (OR = 1.48 (1.03 to 2.12)), lack of family information (OR = 2.02 (2.48 to 2.75)), and lack of discharge report (OR = 3.39 (1.70 to 6.76)). Three independent factors prevent dissatisfaction: age of GPs ≤45 years (OR = 0.69 (0.51 to 0.94)); the GP is called at patient ICU admission (OR = 0.44 (0.31 to 0.63)); and GP involvement in treatment decisions (OR = 0.17 (0.07 to 0.40)).Considerable improvement in GP/intensivist relationships can be achieved through increased communication measures.Because the general practitioner (GP) is a cornerstone of the daily life of the patient and all specialties of the hospital, he or she should be a main communicator with ICU physicians. At patient admission, the GP is the sole medical practitioner who knows the patient's history and his or her way of life. This information could be of particular interest for therapeutic and ethical decisions. In intensive care units (ICUs), GP involvement in the process of family communication is an independent factor of satisfaction among patients' relatives exper
Severe metabolic or mixed acidemia on intensive care unit admission: incidence, prognosis and administration of buffer therapy. a prospective, multiple-center study
Boris Jung, Thomas Rimmele, Charlotte Le Goff, Gérald Chanques, Philippe Corne, Olivier Jonquet, Laurent Muller, Jean-Yves Lefrant, Christophe Guervilly, Laurent Papazian, Bernard Allaouchiche, Samir Jaber, The AzuRea Group
Critical Care , 2011, DOI: 10.1186/cc10487
Abstract: We conducted a prospective, observational, multiple-center study. Consecutive patients who presented with severe acidemia, defined herein as plasma pH below 7.20, were screened. The incidence, sodium bicarbonate prescription and outcomes of either metabolic or mixed severe acidemia were analyzed.Among 2, 550 critically ill patients, 200 (8%) presented with severe acidemia, and 155 (6% of the total admissions) met the inclusion criteria. Almost all patients needed mechanical ventilation and vasopressors during their ICU stay, and 20% of them required renal replacement therapy within the first 24 hours of their ICU stay. Severe metabolic or mixed acidemia was associated with a mortality rate of 57% in the ICU. Delay of acidemia recovery as opposed to initial pH value was associated with increased mortality in the ICU. The type of acidemia did not influence the decision to administer sodium bicarbonate.The incidence of severe metabolic or mixed acidemia in critically ill patients was 6% in the present study, and it was associated with a 57% mortality rate in the ICU. In contradistinction with the initial acid-base parameters, the rapidity of acidemia recovery was an independent risk factor for mortality. Sodium bicarbonate prescription was very heterogeneous between ICUs. Further studies assessing specific treatments may be of interest in this population."Acidemia" can be defined as the accumulation of protons in the plasma which results in a lower blood pH if secondary responses are overwhelmed. In critically ill patients, acidosis is often the result of a combination of single disorders occurring simultaneously that are commonly known collectively as "mixed acid-base disorders" [1-6].Although "severe acidemia" is not a universally accepted term, it usually indicates that plasma pH is lower than 7.20 [3,7,8]. Severe acidemia can be critical, especially when an extremely low pH develops quickly. Clinical manifestations of severe acidemia include cerebral edema, seizure
Programmed death-1 levels correlate with increased mortality, nosocomial infection and immune dysfunctions in septic shock patients
Caroline Guignant, Alain Lepape, Xin Huang, Hakim Kherouf, Laure Denis, Fran?oise Poitevin, Christophe Malcus, Aurélie Chéron, Bernard Allaouchiche, Fran?ois Gueyffier, Alfred Ayala, Guillaume Monneret, Fabienne Venet
Critical Care , 2011, DOI: 10.1186/cc10112
Abstract: This prospective and observational study included 64 septic shock patients, 13 trauma patients and 49 healthy individuals. PD-1-related-molecule expressions were measured by flow cytometry on circulating leukocytes. Plasmatic interleukin (IL)-10 concentration as well as ex vivo mitogen-induced lymphocyte proliferation were assessed.We observed that septic shock patients displayed increased PD-1, PD-Ligand1 (PD-L1) and PD-L2 monocyte expressions and enhanced PD-1 and PD-L1 CD4+ T lymphocyte expressions at day 1-2 and 3-5 after the onset of shock in comparison with patients with trauma and healthy volunteers. Importantly, increased expressions were associated with increased occurrence of secondary nosocomial infections and mortality after septic shock as well as with decreased mitogen-induced lymphocyte proliferation and increased circulating IL-10 concentration.These findings indicate that PD-1-related molecules may constitute a novel immunoregulatory system involved in sepsis-induced immune alterations. Results should be confirmed in a larger cohort of patients. This may offer innovative therapeutic perspectives on the treatment of this hitherto deadly disease.Sepsis remains a major health-care problem worldwide [1]. For example, during the last decade, its hospitalization rate has almost doubled in the US [2]. This is associated with a mortality rate approaching 50% in the case of septic shock [3,4], despite the development of novel treatments such as early appropriate antibiotherapy, early goal-directed therapy, and activated protein C. Therefore, a better understanding of pathophysiology of severe sepsis is a necessity if we are to decrease the high mortality rate of this condition.Septic pathophysiology is a culmination of multiple complex dynamic processes whose interactions are only partially understood. However, it is now accepted that after a rapid proinflammatory response, a counter-regulatory phase characterized by immune alterations impacting both innate
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