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Biomedical subjects

B Guidet

Publications and source records attributed to B Guidet.

At least 19 recordsLinked to original sources
PubMed2006

Prognostic value of inhibitory anti-ADAMTS13 antibodies in adult-acquired thrombotic thrombocytopenic purpura.

In order to assess the prognostic value of inhibitory anti-ADAMTS13 antibodies in thrombotic thrombocytopenic purpura (TTP), we performed a multicentre prospective study of 33 adult patients with idiopathic acquired TTP. Patients were treated with high-dose plasma infusion and therapeutic plasma exchange. Patients without (group 1, n = 12) and with (group 2, n = 21) detectable inhibitory anti-ADAMTS13 antibodies were compared for clinical presentation, treatment and outcome. Both groups were comparable for clinical presentation. All patients in group 1 achieved a sustained complete remission within a median of 7 d [95% confidence interval (CI), 4-18], which required a median plasma volume of 235 ml/kg (range, 131-1251). In group 2, 17 patients achieved a durable complete remission within a median of 23 d (95% CI, 11-32) (P = 0.001). Median plasma volume was 718 ml/kg (range, 219-3107) (P = 0.02). In group 2, there was a trend for more episodes of flare-up than in group 1 (13 vs. 3, respectively, P = 0.07). Four patients, all from group 2, died (P = not significant). The relapse rate was comparable between both groups. We suggest that TTP with detectable inhibitory anti-ADAMTS13 antibodies displays a worse prognosis, relative to a delayed platelet count recovery, a higher plasma volume requirement to achieve complete remission, and a trend for more frequent episodes of flare-up.

ADAM Proteins↗
PubMed2006

International Programme for Resource Use in Critical Care (IPOC)--a methodology and initial results of cost and provision in four European countries.

BACKGROUND: A standardized top-down costing method is not currently available internationally. An internally validated method developed in the UK was modified for use in critical care in different countries. Costs could then be compared using the World Health Organization's Purchasing Power Parities (WHO PPPs). METHODS: This was an observational, retrospective, cross-sectional, multicentre study set in four European countries: France, UK, Germany and Hungary. A total of 329 adult intensive care units (ICUs) participated in the study. RESULTS: The costs are reported in international dollars ($) derived from the WHO PPP programme. The results show significant differences in resource use and costs of ICUs over the four countries. On the basis of the sum of the means for the major components, the average cost per patient day in UK hospitals was $1512, in French hospitals $934, in German hospitals $726 and in Hungarian hospitals $280. CONCLUSIONS: The reasons for such differences are poorly understood but warrant further investigation. This information will allow us to better adjust our measures of international ICU costs.

Costs and Cost Analysis↗
PubMed2006

[The evaluation of health care outcomes and hospital performance indicators].

INTRODUCTION: The assessment of the performance of health care establishments has undergone a considerable development over the past 15 years in the United States and to a lesser extent in other developed countries. BACKGROUND: The aim of measurement of performance indicators is to improve the quality of care (outcomes), patient information and the contractual arrangements with purchasers. However, this approach poses numerous methodological problems in the choice of performance indicators as well as the collection and interpretation of data. Specific structural patterns such as social and geographic environment, research and educational assignments, are often inadequately considered. In terms of public health the impact of the publication of these measurements has not been well studied. Based on the data in the literature this revue defines the measures of hospital performance and describes the main studies, their impacts and limitations. VIEWPOINT: It seems likely that the French public authorities will, in the short term, ask health care establishments to undertake this approach. CONCLUSIONS: Complimentary studies are needed to clarify the links between performance indicators and health care outcomes.

Europe↗
PubMed2003

A monthly systematic bacteriological report improves accuracy of identification of hospital-acquired infections in an ICU.

A prospective cohort study with retrospective validation was initiated in order to assess whether a monthly bacteriological report improves the accuracy in detecting hospital-acquired infections (HAI). The setting was a 14-bed medical intensive care unit (ICU) in a 821 bed French university affiliated hospital. One thousand, six hundred and two patients were admitted during the two-year study period, the mean age was 58+/-19 years, the mean Simplified Acute Physiology Score 2 (SAPS 2) was 34+/-21, and ICU mortality was 14%. The microbiology laboratory sent monthly bacteriological reports of urine samples and central venous catheter (CVC) tips back to the intensive-care unit physician in charge of the HAI surveillance programme. This enabled a comparison to be made between prospectively and retrospectively diagnosed hospital-acquired urinary tract infections (HAUTI) and CVC-related infections (HACVCI), HAUTI were prospectively identified in 51 cases (incidence density=10.03/1,000 days) and 23 more cases were found after receiving the monthly bacteriological report (final HAUTI incidence density=14.6/1,000 days, P<0.05). HACVCI were prospectively recognized in 13 cases (incidence density=4/1,000 days) and eight more cases were discovered (final HACVCI incidence density=6.52/1,000 days,P >0.1). All retrospectively diagnosed HAI occurred during the last 48 h of the patients' ICU stay. We conclude that the routine HAI surveillance programme is reliable, except for the last 48 h in the ICU. The monthly bacteriological report improved the accuracy of the HAI reporting rate.

Adult↗
PubMed2001

Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion?

We evaluated ultrasonic examination as a diagnostic tool for catheter misplacement and pneumothorax after central venous catheter insertion. Physicians in the intensive care unit (ICU) performed the ultrasonic examinations, and the results were compared with those of chest radiography. Eighty-five central venous catheters (70 subclavian and 15 internal jugular) were inserted into 81 patients; 10 misplacements and one pneumothorax occurred. Ultrasonic examination feasibility was 99.6%. The only pneumothorax and all misplacements except one were diagnosed by ultrasound. Taking into consideration misplacements and pneumothorax research, ultrasonic examination did not give any false positive results. The mean time of the entire ultrasonic examination was 6.8 +/- 3.5 min, whereas 80.3 +/- 66.7 min were needed for the radiography (p < 0.0001). This study has suggested that ultrasonic diagnosis of catheter misplacement and pneumothorax related to central venous catheterization is a rapid and accurate method that can be easily performed by ICU physicians.

Adult↗
PubMed2001

A cost-effectiveness analysis of stays in intensive care units.

OBJECTIVE: To evaluate patient outcome and the efficiency of stays in intensive care units (ICUs). DESIGN: Prospective study. SETTING: Seven ICUs of teaching hospitals in the Paris area. PATIENTS: Two hundred eleven stays including one in three consecutive patients admitted from September to November 1996. MEASUREMENTS AND MAIN RESULTS: For each patient, the following information was collected during the ICU stay: diagnosis, severity scores, organ failures, workload, cost and mortality. A cost-effectiveness ratio was computed for 176 stays with at least one organ failure, at hospital discharge and 6 months later. Quality of life was measured with EuroQol questionnaires 6 months after discharge in 64 patients representing 62 % of the patients contacted. The mean total ICU cost per stay was US$ 14,130 (+/- 6,550) (higher for non-survivors--US$ 19,060, median 10,590--than for survivors US$ 12,370, median 5,780). The incremental cost-effectiveness ratio was US$ 1,150 per life-year saved and the incremental cost-utility ratio was US$ 4,100 per quality-adjusted life-year (QALY) saved, without discounting. These results compare favourably with other health-care options. However substantial variations were observed according to age, severity, diagnosis, number of organ failures and discount rate. Intoxication had the lowest ratio (US$ 620/QALY) and acute renal insufficiency the highest (US$ 30,625/QALY). CONCLUSIONS: This work provides medical and economic information on ICU stays in teaching hospitals and enables comparisons with other health-care options.

Adult↗
PubMed2001

Severe accidental hypothermia treated in an ICU: prognosis and outcome.

STUDY OBJECTIVES: To assess the characteristics and outcomes of patients admitted to an ICU for severe accidental hypothermia, and to identify risk factors for mortality. METHODS: All consecutive patients admitted to an ICU between January 1, 1979, and July 31, 1998, with a temperature of < or = 32 degrees C were retrospectively analyzed. Rewarming was always conducted passively with survival blankets and conventional covers. Prognostic factors were studied by means of univariate analysis (Mann-Whitney U and chi(2) tests) and multivariate analysis (logistic regression). RESULTS: Forty-seven patients were enrolled (mean +/- SD age, 61.7 +/- 16 years). Five patients had a cardiac arrest before ICU admission. Patient characteristics at ICU admission were as follows: temperature, 28.8 +/- 2.5 degrees C; systolic BP, 85 +/- 23 mm Hg; heart rate, 60 +/- 24 beats/min; Glasgow Coma Scale, 10.4 +/- 3.7; and simplified acute physiology score (SAPS) II, 50.9 +/- 27. Mechanical ventilation was necessary in 23 cases, and 22 patients in shock received vasoactive drugs. The mean length of stay in the ICU was 6.7 +/- 9 days. Eighteen patients (38%) died, but ventricular arrhythmia was never the cause. Univariate analysis identified several prognostic factors (p < 0.05): age (57 +/- 16 years vs 69 +/- 14 years), systolic arterial BP (93 +/- 20 mm Hg vs 71 +/- 21 mm Hg), blood bicarbonate level (23.5 +/- 5.2 mmol/L vs 16.6 +/- 6.2 mmol/L), SAPS II score (35.3 +/- 19.5 vs 72 +/- 21), mechanical ventilation (34% vs 81%), vasopressor agents (42% vs 82%), rewarming time (11.5 +/- 7.2 h vs 17.2 +/- 7 h), and discovery of the patient at home (2.3% vs 54.5%). The initial temperature did not influence vital outcome (28.9 +/- 2.6 degrees C vs 28.6 +/- 2.2 degrees C). Only the use of vasoactive drugs (odds ratio, 9; 95% confidence interval, 1.6 to 50.1) was identified as a prognostic factor in the multivariate analysis. CONCLUSION: Severe accidental hypothermia is a rare cause of ICU admission in an urban area. Its mortality remains high, but there is no overmortality according to the SAPS II-derived prediction of death. Shock, requiring treatment with vasoactive drugs, is an independent risk factor for mortality, while initial core temperature is not. It remains to be determined whether aggressive rather than passive rewarming procedures are better.

Adult↗
PubMed2000

Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit.

We investigated whether rubbing with an alcohol solution increases compliance with hand disinfection in a medical intensive care unit (MICU). During a first period (P1), hand disinfection was achieved only through conventional washing, whereas during a second period (P2), hand disinfection could be achieved either through conventional washing or rubbing with an alcohol solution. There were 621 opportunities for hand disinfection during P1 and 905 opportunities during P2. General compliance during P1 was 42.4%, and reached 60.9% during P2 (p < 0.001). This improvement was observed among nurses (45.3% versus 66.9%, p < 0.001), senior physicians (37. 2% versus 55.5%, p < 0.001), and residents (46.9% versus 59.1%, p = 0.03). Acceptability and tolerance were evaluated through the answers to an anonymous questionnaire distributed to all 53 health care workers in the MICU. Rubbing with alcohol solution was an easy procedure (100% of responses) and induced mild side effects in less than 10% of respondents. In a complementary study conducted 3 mo after the first one, compliance remained better than during P1 (51. 3% versus 42.4%, p = 0.007). These findings suggest that rubbing with alcohol solution increases compliance with hand disinfection, and that it could be proposed as an alternative to conventional handwashing in the MICU.

Attitude of Health Personnel↗
PubMed2000

Bedside detection of retained tracheobronchial secretions in patients receiving mechanical ventilation: is it time for tracheal suctioning?

OBJECTIVE: To identify parameters that indicate retained secretions and the need for tracheal suctioning (TS) in patients receiving mechanical ventilation (MV). DESIGN: Prospective observational study. SETTING: A 14-bed medical ICU in a 946-bed university hospital. PATIENTS: Sixty-six consecutive patients receiving MV. INTERVENTIONS: Two successive tracheal suctions, TS1 and TS2, performed at a 2-h interval as usual patient care. Retained secretions were considered significant if the volume of secretions removed by TS2 was > 0.5 mL. MEASUREMENTS AND RESULTS: Variations between TS1 and TS2 of pulse oximetric saturation (SpO(2)), peak inspiratory pressure (Ppeak), tidal volume (VT), and Ramsay score were compared between patients with TS2 < or = 0.5 mL (group 1; n = 27) and patients with TS2 > 0.5 mL (group 2; n = 39). The presence of a sawtooth pattern on flow-volume loop displayed on the monitor screen of the ventilator and of respiratory sounds heard over the trachea before TS2 were compared between the two groups. Variations of Ppeak, VT, SpO(2), and Ramsay score between TS1 and TS2 did not differ between the two groups. However, group 2 had a sawtooth pattern (82% vs 29.6%; p = 0.0001) and respiratory sounds (66.6% vs. 25.9%; p = 0. 001) more frequently than group 1 before TS2. For the sawtooth pattern, the likelihood ratio (LR) of a positive test was 2.70 and the LR of a negative test was 0.25, while for respiratory sounds it was 2.50 and 0.45, respectively. When the presence of a sawtooth pattern and of respiratory sounds was combined, the LR of a positive test rose to 14.7 and the LR of a negative test was 0.42. CONCLUSIONS: A sawtooth pattern and/or respiratory sounds over the trachea are good indicators of retained secretions in patients receiving MV and may indicate the need for TS. Conversely, the absence of a sawtooth pattern may rule out retained secretions.

Bronchi↗
PubMed1999

Prolonged sedation requiring mechanical ventilation and continuous flumazenil infusion after routine doses of clorazepam for alcohol withdrawal syndrome.

We report the cases of two patients who developed prolonged sedation after routine doses of clorazepam for alcohol withdrawal syndrome. They required prolonged mechanical ventilation (10 days for both patients) followed by continuous flumazenil infusion (16 days for one patient and 3 days for the other) to avoid reintubation. In the two patients, nordazepam accumulation (main active metabolite of clorazepam) was demonstrated as the cause of the coma. This accumulation could be attributed, in one case, to impaired hepatic cytochrome P 450 3A4 activity. Caution is required when prescribing benzodiazepines to alcoholic patients and the use of benzodiazepine which do not undergo hepatic oxidation by cytochrome P 450 such as oxazepam or lorazepam is suggested.

Aged↗
PubMed1999

Acute renal failure in rhabdomyolysis.

Fifteen to 30% of patients develop acute renal failure (ARF) following rhabdomyolysis and rhabdomyolysis accounts for 5 to 9% of all ARF. Experimental studies revealed two critical factors that predispose to myoglobinuric ARF: hypovolemia/dehydration and aciduria. At the nephron level, three basic mechanisms underlie heme protein toxicity: renal vasoconstriction with decreased renal blood flow, intraluminal cast formation and direct heme protein-induced cytotoxicity. During the early phase of myoglobinuric ARF, hemodynamic process are mainly involved in glomerumar filtration rate decrease while tubular mechanisms occur in the late phase. Critical factors which predispose to myoglobinuric ARF in animal models--i.e. hypovolemia/dehydration and aciduria--are also encountered in human epidemiological studies. Prevention of myoglobinuric ARF rely on rapid and adequate correction of fluid deficits with saline, bicarbonates and mannitol. The choice of hemodialysis technique in the case of constituted ARF strongly depends on the site of intervention, especially in the case of rescue operation. The care of myoglobinuric ARF in intensive care unit do not differ from this of ARF from other causes.

Acute Kidney Injury↗
PubMed1998

[Guillain-Barré syndrome in the adult: therapeutic aspects].

The Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. The current mortality is 5%, while severe motor sequelae persist after one year in 10%. Multidisciplinary teams, trained in all specific treatments, are required to treat these patients. Oral and intravenous steroids have proved ineffective. Two large randomized clinical trials comparing plasma exchange (PE) with no treatment have shown a short-term and a 1-year benefit. The appropriate number of exchanges and the indications are now more precisely known. In the mild form (walking possible) patients should receive two PEs; a further two exchanges should be done in the event of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). More exchanges are not beneficial. Recently two new randomized trials have produced evidence that intravenous immunoglobulin (IVIg) (0.4 g/kg/day for 5 days) was as effective as 5 PEs in advanced forms. The combination of PE with IVIg did not confer a significant advantage but increased the costs and risks. In advanced forms the choice between PE and IVIg depends on the contraindications for each treatment.

Adult↗