Désescalade de l’antibiothérapie en réanimation

Successful treatment of severe infections in the intensive care unit (ICU) often requires broad-spectrum empiric therapy, while attempting to control the source of infection. However, this liberal antibiotic strategy may be associated with adverse effects on the patients as well as on the overall microbial ecology of the unit. This “antibiotic dilemma” may be solved by early de-escalation of antibiotic therapy, which allows reducing the overall antibiotic exposure of ICU patients by shortening the duration of therapy (including early stop when infection is not confirmed), switching from combined to single therapy, and/or substituting broad-spectrum agent with narrower-spectrum regimen. The opportunity for de-escalation varies across series from 20% to 50%, depending on the empiric antibiotic policy and the epidemiological context. Adapting the antibiotic regimen, possible as early as 24 h after obtaining the first results from adequate samples, is mandatory at 48–72 h, once full microbiological results are obtained. Subsequently, the intensivist must reassess daily the continued need for antibiotics, just like sedation is reassessed daily in mechanically ventilated patients. Several studies have confirmed that early deescalation is safe, and recent evidence suggests that it may even be associated with improved outcome of patients.     

Introduction à l’analyse de la performance en réanimation

Performance assessment of ICU should be multidimensional and adapted to the specificity of each unit (type of hospital, missions). The media are fond of simple indicators enabling ranking of units or hospital. These indicators do not consider the specificity of each unit (case mix, constrains) and are integrated in a single composite score with an arbitrary weight for each item. Each unit should follow different indicators covering different aspects of performance. These indicators should be gathered in a “tableau de bord” and need to be discussed by the whole team and integrated in a quality improvement process. The performance indicators should be considered as tools used in order to improve the internal management, to ease the discussion with the administration and to improve the information delivered to “customers” of the ICU (patients, referring physicians).     

Intérêt de l’évaluation quantitative des sources d’inconforts en réanimation

Potential sources of discomfort or stressors associated with an intensive care unit (ICU) stay can be classified as intrinsic or patient-related factors, environmental factors (such as noise and excess of light), and organizational factors. Two approaches facilitate the assessment of ICU-related stressors: first an objective approach by measuring physical or physiological parameters that characterize either ICU-related stressors or their impact on the critically ill patient, and second, a subjective approach using questionnaires (patient-related outcomes). Pain is frequently reported by ICU patients as the main stressful condition, in relation to many therapeutic or diagnostic procedures. Thirst and sleep deprivation are also perceived very negatively by ICU patients in studies based on questionnaires investigating patient-related outcomes. ICU stays without control of stressors may induce agitation and confusion (ICU psychosis) and increase the risk of developing a post-traumatic stress disorder. Promoting the IPREA (Inconforts des Patients de REAnimation, discomfort in critically ill patients) questionnaire and its implementation in routine clinical practice could be the starting point for the development of quality assurance programs based on the Deming Approach—PDCA “Plan Do Check Act.”     

Intérêt de l’échographie thoracique et musculaire en kinésithérapie de réanimation

Ultrasonography has been used for many years by physiotherapists in the English-speaking countries. But its application to intensive care unit physiotherapy is a new trend and is gaining wide acceptance. Thoracic ultrasound allows the physiotherapist to assess the patient with more accuracy, allowing optimization of the treatment choice and monitoring. Muscular ultrasound allows the physiotherapist to make an assessment of intensive care unit-acquired weakness in the patient and follow up on recovery. Qualitative and quantitative muscle evolution may be a useful indicator of the patient’s severity status and of treatment efficacy. The use of ultrasonography by the physiotherapists is beneficial and should be supported and developed.     

Méningoencéphalites infectieuses de l’adulte non immunodéprimé en réanimation

Encephalitis refers to an acute or subacute, inflammatory process affecting the brain in association with clinical evidence of neurologic manifestations such as altered consciousness, seizures or focal disturbances and cerebrospinal fluid abnormalities. This clinical syndrome is associated with a number of infectious, post-infectious, and non-infectious causes. An infection by a virus is the most common and important cause of encephalitis, although bacteria and parasites may sometimes be responsible for this syndrome. Three recent multicentre studies conducted in the USA, France and England, respectively, have shown that extensive testing may substantially reduce the proportion of unknown causes, which still varies from 37 to 70%.Magnetic resonance imaging is the most sensitive neuroimaging test to evaluate patients with encephalitis, while performing nucleic acid amplification by polymerase chain reaction (PCR) of CSF specimens may increase the ability to identify certain etiologic agents. Herpes simplex virus is the most frequent cause of sporadic necrotizing encephalitis and is the most frequently identified pathogen. Since Herpesviral encephalitis is associated with a substantial incidence of mortality and severe disability, early acyclovir therapy should be initiated in all patients with suspected encephalitis, pending results of neuroimaging and PCR testing. The number of emerging infectious diseases (EIDs) and the magnitude of their threat to global health is increasing. Viral EID’s may produce severe neurologic symptoms including encephalitis. In patients with encephalitis and a history of recent illness, the diagnosis of acute disseminated encephalomyelitis should be considered.     

Surveillance et évaluation de l’efficacité de la nutrition artificielle en réanimation

In the intensive care unit (ICU), nutrition support is a part of patients’ management. As for ventilation and hemodynamics, nutrition and metabolism monitoring is mandatory for improving tolerance and efficacy of nutrition support. Enteral nutrition (EN) is commonly associated with protein-energy deficiency, which is related to poor prognosis. Early detection of deficiency should lead to increase protein and energy delivery, including EN-parenteral nutrition (PN) combination. Overfeeding-related metabolic complications of PN should be screened. Glycaemic monitoring is requested since glycaemic control may result in decreased mortality. In the ICU, macro- and micronutriment intakes, energy expenditure, and matching between protein-energy target and delivery, should be tightly monitored. This monitoring should be computer-based and integrated in patients’ management. An ICU dedicated dietitian may allow to decrease energy deficiency. Since weight, height, serum albumin, and transthyretin could be unsufficient for any definitive diagnosis, assessment of body composition may be useful to allow an accurate assessment of nutrition support efficacy during ICU stay. By limiting protein-energy deficiency and overfeeding and by optimizing glycaemic control, nutrition and metabolism monitoring should improve clinical outcome. Future studies will be helpful to determine the medico-economic impact of nutrition and metabolism monitoring.     

La visite de l’enfant en réanimation adulte : une visite préparée

Intensive care units are places for providing advanced technical support in units where you encounter a potentially hostile and impressive visual, olfactive, and auditory environment. Patients have a severe health condition with an uncertain prognosis for survival. Considering both the threatened life and the hostile environment, the visit of a child who is vulnerable and innocent may arouse fears and reluctances within the nursing staff. Nevertheless, we consider it relevant to bring up an organization to watch over the visiting child (even young ones). This visit can allow the child to share with the rest of the family his (her) own real-life experience of the situation and to stay connected with his (her) hospitalized relative. Being able to put words and images on the situation is a way to soothe fears and fantasies that occur when children are kept in ignorance. This visit must be accompanied and prepared by the whole team; its organization requires several preliminary steps. This initiative implies the accompaniment of a psychologist who will analyse the request, the psychological implications, the family system, and prepare the child. We present through this article, a series of steps to follow to accompany the child visitor to the intensive care unit).     

Sédation inhalée en réanimation: que reste-t-il de l’AnaConDa™ ?

Sedation contributes to patient’s comfort and plays an essential role in the intensive care unit (ICU). Several clinical studies have reported the occasional use of volatile halogenated agents in the ICU; however, long-term use is possible in routine for the provision of a dedicated evaporator filter (AnaConDa? [ACD]). Because of their low cost and pharmacological characteristics with a rapid therapeutic effect, a high therapeutic index, a possible use regardless of age and underlying medical conditions, and a good knowledge of their adverse effects, halogenated agents could be considered like possible ideal anesthetic agents in the ICU. The objective of this technical note is to clarify the potential indications of ACD device and describe its operative principles and potential drawbacks.     

Transfusions de plasma en réanimation pédiatrique

Whereas red blood cell transfusions have been used since the nineteenth century, plasma has only been available since 1941. It was originally mainly used as volume replacement, mostly during World War II and the Korean War. Over the years, its indication has shifted to correcting coagulation factors deficiencies or to preventing bleeding. Currently, it remains a frequent treatment in the intensive care unit, both for critically ill adults and children. However, observational studies have shown that plasma transfusion fail to correct mildly abnormal coagulation tests. Furthermore, recent epidemiological studies have shown that plasma transfusions are associated with an increased morbidity and mortality in critically ill patients. Therefore, plasma as any other treatment has to be used when the benefits outweigh the risks. Based on observational data, most experts suggest limiting its use either to massively bleeding patients, or bleeding patients who have documented abnormal coagulation tests, and refraining for transfusing plasma to non-bleeding patients whatever their coagulation tests. In this paper, we will review current evidence on plasma transfusions and discuss its indications.     

Probiotiques en réanimation

An acknowledgment of the crucial role of intestinal tract and digestive flora has aroused growing interest in the use of probiotics (defined as “live microorganisms that, when administered in adequate amount, confer a beneficial health effect”) during various intestinal disorders such as chronic inflammatory bowel disease, antibiotic-associated diarrhea, and extra-digestive diseases, namely atopic dermatitis, allergy, and asthma. However, clinical data related to their use in the intensive care unit, especially with the aim to prevent ventilator-associated pneumonia, are scarce and conflicting. We hereby review and discuss the usefulness of probiotics in critically ill patients.