The decision-making process for the intensity of care delivered to patients with lung cancer and organ failure is poorly understood, and does not always involve intensivists. Our objective was to describe the potential suitability for intensive care unit (ICU) referral of lung cancer in-patients with organ failures. We prospectively included consecutive lung cancer patients with failure of at least one organ admitted to the teaching hospital in Grenoble, France, between December 2010 and October 2012. Of 140 patients, 121 (86%) were evaluated by an oncologist and 49 (35%) were referred for ICU admission, with subsequent admission for 36 (73%) out of those 49. Factors independently associated with ICU referral were performance status ⩽2 (OR 10.07, 95% CI 3.85–26.32), nonprogressive malignancy (OR 7.00, 95% CI 2.24–21.80), and no explicit refusal of ICU admission by the patient and/or family (OR 7.95, 95% CI 2.39–26.37). Factors independently associated with ICU admission were the initial ward being other than the lung cancer unit (OR 6.02, 95% CI 1.11–32.80) and an available medical ICU bed (OR 8.19, 95% CI 1.48–45.35). Only one-third of lung cancer patients with organ failures were referred for ICU admission. The decision not to consider ICU admission was often taken by a non-intensivist, with advice from an oncologist rather than an intensivist.
L’infection liée aux cathéters veineux centraux, événement grave en grande partie évitable, est la principale cause de bactériémie nosocomiale. Les bactériémies associées aux cathéters et liées aux cathéters doivent être bien distinguées. En l’absence de signes locaux patents, de sepsis sévère, d’immunodépression ou de matériel prothétique en place, la réalisation d’hémocultures qualitatives comparatives par le cathéter et en périphérie peut faire le diagnostic d’implication du cathéter sans obliger à son ablation. Des taux de bactériémies liées aux cathéters (définition du consensus français) supérieurs à 1 pour 1000 journéescathéters doivent être considérés comme inacceptables. La mise en place d’un programme de prévention en réanimation est réalisable et le plus souvent efficace pour faire diminuer les taux d’infections, motiver et restructurer les équipes de soins. Si les taux d’infections sont élevés, la mise en place de mesures simples (renforcement de l’hygiène des mains, asepsie chirurgicale à la pose, solutions antiseptiques contenant de l’alcool, voie sous-clavière préférentielle, procédure d’entretien des cathéters et des lignes de perfusion, réfection immédiate des pansements souillés ou décollés, ablation des cathéters inutiles) et adaptées au mode de fonctionnement du service sont efficaces. Une gouvernance claire et une rétroinformation sont indispensables au succès de ces programmes d’amélioration de la qualité des soins. Si les taux restent élevés, ou si l’on veut aller plus loin, les pansements imprégnés de chlorhexidine permettent de diminuer encore le risque d’infection. L’utilisation des cathéters imprégnés d’agents antimicrobiens doit être limitée aux situations d’échec de la politique globale de prévention.
To estimate the rate of pulmonary embolism among mechanically ventilated patients and its association with deep venous thrombosis.Prospective cohort study.Medical intensive care unit of a university-affiliated teaching hospital.mechanically ventilated patients requiring a thoracic contrast-enhanced computed tomography scan for any medical reason.a diagnosis of pulmonary embolism before intensive care unit admission, an allergy to contrast agents, and age younger than 18 yrs.All the mechanically ventilated patients requiring a thoracic computed tomography underwent the standard imaging protocol for pulmonary embolism detection. Therapeutic anticoagulation was given immediately after pulmonary embolism diagnosis. All the included patients underwent a compression ultrasound of the four limbs within 48 hrs after the computed tomography scan to detect deep venous thrombosis.Of 176 included patients, 33 (18.7%) had pulmonary embolism diagnosed by computed tomography, including 20 (61%) with no clinical suspicion of pulmonary embolism. By multiple logistic regression, independent risk factors for pulmonary embolism were male gender, high body mass index, history of cancer, past medical history of deep venous thrombosis, coma, and high platelet count. Previous prophylactic anticoagulant use was not a risk factor for pulmonary embolism. Of the 176 patients, 35 (19.9%) had deep venous thrombosis by compression ultrasonography, including 20 (57.1%) in the lower limbs and 24 (68.6%) related to central venous catheters. Of the 33 pulmonary embolisms, 11 (33.3%) were associated with deep venous thrombosis. The pulmonary embolism risk was increased by lower-limb deep venous thrombosis (odds ratio 4.0; 95% confidence interval 1.6-10) but not upper-limb deep venous thrombosis (odds ratio 0.6; 95% confidence interval 0.1-2.9). Crude comparison of patients with and without pulmonary embolism shows no difference in length of stay or mortality.In mechanically ventilated patients who needed a computed tomography, pulmonary embolism was more common than expected. Patients diagnosed with pulmonary embolism were all treated with therapeutic anticoagulation, and their intensive care unit or hospital mortality was not impacted by the pulmonary embolism occurrence. These results invite further research into early screening and therapeutic anticoagulation of pulmonary embolism in critically ill patients.
Background. Although hypothermia is widely accepted as a risk factor for subsequent infection in surgical patients, it has not been well defined in medical patients. We sought to assess the risk of acquiring intensive care unit (ICU)--acquired infection after hypothermia among medical ICU patients.
Being able to better predict risk and optimal care for patients presenting with acute dyspnea is critical. Prognostic biomarkers are well known: amino-terminal pro-B-type Natriuretic Peptide, troponin, C-reactive protein, procalcitonin. Some were more recently developed: mid-regional pro-A-type natriuretic peptide (Mid Pro-ANP), mid-regional-pro-adrenomedullin (MR-proADM), pro-endothelin, copeptin. The aim of the paper was to evaluate prognostic value of clinical findings and 8 biomarkers in patients with severe acute dyspnea.We designed a prospective cohort study targeting patients admitted in the Emergency Department and in Intensive Care Unit of a University Hospital. Inclusion criteria were acute dyspnea with SpO2 less than 92% and/or respiratory rate (RR) greater than or equal to 25 bpm. Clinical and biological data, including biomarker levels, were recorded. The contribution of the biomarkers in the prognosis was assessed using AUC-ROC curves and by multiple logistic regression.Three hundred and eighty four patients (median age 74 years, 28-day mortality 17%) were enrolled. All biomarkers were available for 317 patients. Main diagnoses were sepsis in 141 cases (36.7%), and acute heart failure in 84 (21.9%) cases. All biomarkers were correlated with prognosis. Pro-ADM (AUC-ROC=0.731; 95% CI: 0.658-0.804) showed the best accuracy. The parameters independently associated with prognosis led to a clinical/biological model with an AUC=0.809 and a good calibration (P (HLchi2)=0.9). Three biomarkers added prognostic information to the model: MR-proADM (P=0.005), copeptin (P=0.006) and troponin (P=0.05).Biomarkers can contribute to determine the day-28 outcome of patients with acute severe dyspnea.
Le cancer bronchopulmonaire (CBP) est la première cause de mortalité par cancer, tous sexes confondus. Depuis dix ans, le pronostic des patients porteurs d’un CBP, en particulier les adénocarcinomes, s’est amélioré avec le développement des thérapies ciblées. La survie des patients porteurs d’un CBP admis en réanimation est actuellement entre 50 et 70 % avec une survie à six mois de 30 %. Les patients peuvent être présentés au réanimateur lors du diagnostic ou au cours de l’évolution de la maladie tumorale. Les critères pronostiques liés à la pathologie cancéreuse sont le statut métastatique, le performance status, l’état de dénutrition et l’existence d’éventuelles mutations. Les éléments liés à la situation aiguë (admission pour insuffisance respiratoire ou sepsis, score de gravité élevé) apparaissent également associés à la mortalité. Cependant, ces éléments ne suffisent pas pour prendre la bonne décision. La discussion d’admission et de prise en charge des défaillances d’organes doit être collégiale, intégrant l’oncologue, le réanimateur, le patient et son entourage. En l’absence de certitude, une « réanimation d’attente » peut être expliquée et proposée. L’intensité des traitements doit être réévaluée après trois à cinq jours, la non-amélioration des défaillances d’organes à ce stade étant un élément pronostique discriminant. L’apport d’un séjour en réanimation sur la qualité de la vie gagnée n’a pas été suffisamment étudié.
