Place de la réanimation chez le cirrhotique

In cirrhotic patients, liver insufficiency and portal hypertension represent a source of potentially life threatening complications, which may justify intensive care. In addition to specific complications (variceal bleeding, hepatic encephalopathy and hepatorenal syndrome), cirrhosis is a condition which favors non-specific complications including severe bacterial infections and acute renal failure. Apart from these complications, cirrhosis is constantly associated with dysfunctions of several organs and systems (cardiocirculatory system, respiratory system, central nervous system, immune system and coagulation). When severe complications occur, dysfunctions of these organs and system can progress and lead to multi-organ failure. As a result, the prognosis of cirrhotics in intensive care units is poor. A major issue is to determine which patients should be admitted to intensive care. Different prognostic scores have been proposed but none is perfect. Practically, admission in an intensive care unit is justified in the absence of significant hepatic insufficiency or when hepatic insufficiency is reversible, when liver transplantation is possible, and in case of iatrogenic complications. In other conditions, mortality is close to 100% and intensive care may not be justified. Theoretically, the correction of hepatic insufficiency could help to improve the results of intensive care in cirrhotic patients. The tolerance and efficacy of artificial liver support systems (albumin dialysis and bioartificial liver) remain unclear. However, these systems offer attractive perspectives.     

Mesure de la performance économique en réanimation

The aim of this work is to evaluate the economic efficiency of French intensive care units (ICUs). We develop a two-stage model. In the first step, we use an extended Data Envelopment Analysis model to evaluate the performance of ICUs at the patient level. Few applied works use patient data to gauge efficiency of health care organizations. From a methodological viewpoint, we introduce a directional distance function to gauge performance for each patient in terms of global ICU resources. From an empirical viewpoint, we introduce validated resource utilization indexes (medical and nursing dimensions) and we also control for case-mix heterogeneity with categorical variables including relevant individual measures of illness severity (SAPS II). Data come from a French survey including 15 178 patients of 26 ICUs in the region of Paris over the year 2000. Results show potential savings up to 30% of ICU’s resources and a strong concentration of inefficiency over 20% 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).     

Staphylococcus aureus résistant à la méticilline en réanimation

Methicillin resistant Staphylococcus aureus (MRSA) is responsible for a large number of infections in the intensive care unit (ICU). Severe infections related to MRSA are associated with a high rate of mortality and morbidity. However, after adjustment for confounding factors, mortality is similar in patients with infections related to MRSA and those with infections related to methicillinsensitive S. aureus. The prevalence of MRSA has dramatically decreased in France, which is due to the preventive measures used in ICUs and hospitals. Strains of MRSA that are resistant or intermediate to vancomycin are rare in France. Community-acquired MRSA, which are also rare in France, are responsible for increased mortality because of their higher virulence compared to healthcare-associated strains. Genomic characteristics allow differentiating community-acquired from healthcare-associated MRSA strains. The objective of this review is to provide recent epidemiologic data on MRSA, and to discuss recent findings on preventive measures aiming to reduce the spread of MRSA.