Search PubMed⌕ Search

Biomedical subjects

C Brun-Buisson

Publications and source records attributed to C Brun-Buisson.

At least 55 records · Page 3Linked to original sources
PubMed1999

Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. SRLF Collaborative Group on Mechanical Ventilation. Société de Réanimation de Langue Française.

OBJECTIVE: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. DESIGN: A prospective, multi-institutional, initial cohort study including 28-day follow-up. SETTINGS: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). PATIENTS: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO(2)/FIO(2) ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray); group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F </= 300 mmHg and bilateral infiltrates) and group 3 to patients with P/F of 300 mmHg or less but having exclusion criteria from the previous groups. RESULTS: Nine hundred seventy-six patients entered the ICUs during the study period, 43 % of them being mechanically ventilated and 213 (22 %) meeting the criteria for one of the three groups. Among all the ICU admissions, ARDS, ALI and group 3 patients amounted, respectively, to 6.9 % (67), 1.8 % (17) and 13.3 % (129) of the patients, and represented 31.5 %, 8.1 % and 60.2 % of the hypoxemic, ventilated patients. The overall mortality rate was 41 % and was significantly higher in ARDS patients than in the others (60 % vs 31 % p < 0.01). In group 3, 42 patients had P/F less than 200 mmHg associated with unilateral lung injury; mortality was significantly lower (40.5 %) than in the ARDS group. In the whole group of hypoxemic, ventilated patients, septic shock and severity indices but not oxygenation indices were significantly associated with mortality, while the association with immunosuppression revealed only a trend (p = 0.06). CONCLUSIONS: In this survey we found that very few patients fulfilled the ALI non-ARDS criteria and that the mortality of the group with ARDS was high.

Adult↗
PubMed1999

Corticosteroids as adjunctive therapy for severe Pneumocystis carinii pneumonia in non-human immunodeficiency virus-infected patients: retrospective study of 31 patients.

The aim of this retrospective study was to assess whether corticosteroid adjunctive therapy (CAT) could prevent death in immunocompromised patients with severe Pneumocystis carinii pneumonia (PCP) who do not have human immunodeficiency virus (HIV) infection, similarly to what has been demonstrated for HIV-infected patients. The charts of all non-HIV-infected patients who were admitted to two medical intensive care units between 1988 and 1996 because of severe PCP, defined by an arterial oxygen pressure (determined while the patient was breathing room air) of <70 mm Hg, and who were treated with trimethoprim-sulfamethoxazole were analyzed retrospectively. Thirty-one patients met the study criteria, of whom 23 received CAT (within 72 hours of antibiotic therapy) and eight did not receive CAT. The need for mechanical ventilation (10 [43%] of 23 vs. 4 [50%] of 8) and the mortality rate (9 [39%] of 23 vs. 4 [50%] of 8) were similar for the two groups. Although this small study does not have a statistical power high enough to rule out the possibility of a difference, the results suggest that CAT does not improve the survival of non-HIV-infected patients as has been described for HIV-infected patients with severe PCP.

Adolescent↗
PubMed1999

The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group.

To evaluate the attributable morbidity and mortality of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, we conducted a prospective, matched cohort study. Patients expected to be ventilated for > 48 h were prospectively followed for the development of VAP. To determine the excess ICU stay and mortality attributable to VAP, we matched patients with VAP to patients who did not develop clinically suspected pneumonia. We also conducted sensitivity analyses to examine the effect of different populations, onset of pneumonia, diagnostic criteria, causative organisms, and adequacy of empiric treatment on the outcome of VAP. One hundred and seventy-seven patients developed VAP. As compared with matched patients who did not develop VAP, patients with VAP stayed in the ICU for 4.3 d (95% confidence interval [CI]: 1.5 to 7. 0 d) longer and had a trend toward an increase in risk of death (absolute risk increase: 5.8%; 95% CI: -2.4 to 14.0 d; relative risk (RR) increase: 32.3%; 95% CI: -20.6 to 85.1%). The attributable ICU length of stay was longer for medical than for surgical patients (6. 5 versus 0.7 d, p < 0.004), and for patients infected with "high risk" organisms as compared with "low risk" organisms (9.1 d versus 2.9 d). The attributable mortality was higher for medical patients than for surgical patients (RR increase of 65% versus -27.3%, p = 0. 04). Results were similar for three different VAP diagnostic criteria. We conclude that VAP prolongs ICU length of stay and may increase the risk of death in critically ill patients. The attributable risk of VAP appears to vary with patient population and infecting organism.

Critical Illness↗
PubMed1999

A model to compute the medical cost of patients in intensive care.

OBJECTIVE: Our objective was to identify, among the information routinely collected on patients in intensive care units (ICUs), data that determine the total cost for a given patient. DESIGN: We developed a model that could help physicians in medical ICUs to estimate the cost of care for their patients when no cost data were available at the individual patient level. SETTING: A Medical ICU. PATIENTS AND PARTICIPANTS: The model was developed using a random sample of 73 patients admitted to the medical ICU in 1996 and 1997, validated by another random sample of 29 patients admitted during the same period. INTERVENTIONS: The actual medical variable cost per patient was computed from data on the total resources used (excluding personnel and fixed costs), collected from the patients' records plus pharmacy, laboratory and blood bank logs. The explanatory variables tested were: length of stay, nursing workload, severity of condition, and procedures recorded by a score [omega (omega)] including 3 components related to the frequency of procedure use. The model was constructed in a stepwise fashion, assuming a linear relation. Equations were tested on the basis of the residual mean square; criteria for inclusion and elimination of variables were the level of its partial regression coefficient and medical criteria. The model was validated by analysis of variance of the regression on a second population of 29 patients using the F-test. MAIN OUTCOME MEASURES AND RESULTS: The median length of stay was 7 days (range: 3 to 22 days). Mortality rate was 25%. Median medical variable cost was 805 Pounds (mean medical variable cost was 1738 Pounds, total cost was 6279 Pounds). The variables selected in the multiple regression model as relevant predictors of medical costs were: procedures recorded only once during the ICU stay irrespective of their reiteration (omega 1), procedures recorded every time they are performed (omega 2), procedures recorded daily in the ICU (omega 3) and the presence or absence of an invasive procedure (Kc). The final equation, calibrated with r2 of 0.826 and p > 0.0001, was: medical cost (Pounds) = 23 omega 1 + 53 omega 2 + 8 omega 3 + 2352Kc + 96. The validation with the other sample of 29 patients compared actual to predicted costs. Analysis of variance of the regression from the model was r2 = 0.596 (p > 0.05). CONCLUSIONS: Our standardised cost model is a possible approach to allow comparison of medical costs within and between ICUs.

Adult↗
PubMed1999

Development of a Web-based clinical information system for surveillance of multiresistant organisms and nosocomial infections.

To optimize the surveillance and control of infections at our hospital, we have developed a clinical information system (CIS) linked to a server providing three kinds of patient-oriented data reports: 1/an automated alert for multiresistant bacteria from a data-driven mechanism; 2/the relevant data for surveillance of hospital-acquired infections; 3/some clinical and educational data for antibiotic prescribing. The new CIS is a Web-based one and now integrated to the Hospital Information System (HIS). In a close collaboration with the experts, we have, first, specified the relevant information for each report. Then, we have linked the system to those HIS DBs containing this information. Finally we have developed a well-secured intranet Web site, on which the concerned practitioners can instantaneously review the latest alerts and/or the summarized/detailed reports. The preliminary results shows that the system is reliable in medical practice and the response time is satisfying.

Algorithms↗
PubMed1998

Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis (TEN) is associated with a 30% death rate. Tumour necrosis factor alpha (TNF-alpha) has been implicated in the pathogenesis of TEN. Thalidomide is a potent inhibitor of TNF-alpha action. We did a double-blind, randomised, placebo-controlled study of thalidomide in TEN. METHODS: The patients received a 5-day course of thalidomide 400 mg daily or placebo. The main endpoint was the progression of skin detachment after day 7. Secondary endpoints were the severity of the disease, evaluated with the simplified acute physiology score (SAPS), and the mortality. TNF-alpha and interleukin 6 were measured. FINDINGS: The study was stopped because there was excess mortality in the thalidomide group--ten of 12 patients died compared with three of ten in the placebo group (Fisher's exact test with Katz's approximation, relative risk=2.78, p=0.03). After adjustment for SAPS, mortality remained significantly higher in the thalidomide group than in the placebo group (exact logistic regression mid-p=0.007; 95% CI for odds ratio 2.7 to infinity). Plasma TNF-alpha concentration was higher in the thalidomide group than the placebo group on day 2, though the difference was not significant (Wilcoxon rank-sum test p=0.07). INTERPRETATION: Even though few patients were included, our data suggest that thalidomide is detrimental in TEN, possibly because of a paradoxical enhancement of TNF-alpha production.

Adult↗
PubMed1998

Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients.

BACKGROUND: Understanding the risk factors for ventilator-associated pneumonia can help to assess prognosis and devise and test preventive strategies. OBJECTIVE: To examine the baseline and time-dependent risk factors for ventilator-associated pneumonia and to determine the conditional probability and cumulative risk over the duration of stay in the intensive care unit. DESIGN: Prospective cohort study. SETTING: 16 intensive care units in Canada. PATIENTS: 1014 mechanically ventilated patients. MEASUREMENTS: Demographic and time-dependent variables reflecting illness severity, ventilation, nutrition, and drug exposure. Pneumonia was classified by using five methods: adjudication committee, bedside clinician's diagnosis, Centers for Disease Control and Prevention definition, Clinical Pulmonary Infection score, and positive culture from bronchoalveolar lavage or protected specimen brush. RESULTS: 177 of 1014 patients (17.5%) developed ventilator-associated pneumonia 9.0 +/- 5.9 days (median, 7 days [interquartile range, 5 to 10 days]) after admission to the intensive care unit. Although the cumulative risk increased over time, the daily hazard rate decreased after day 5 (3.3% at day 5, 2.3% at day 10, and 1.3% at day 15). Independent predictors of ventilator-associated pneumonia in multivariable analysis were a primary admitting diagnosis of burns (risk ratio, 5.09 [95% CI, 1.52 to 17.03]), trauma (risk ratio, 5.00 [CI, 1.91 to 13.11]), central nervous system disease (risk ratio, 3.40 [CI, 1.31 to 8.81]), respiratory disease (risk ratio, 2.79 [CI, 1.04 to 7.51]), cardiac disease (risk ratio, 2.72 [CI, 1.05 to 7.01]), mechanical ventilation in the previous 24 hours (risk ratio, 2.28 [CI, 1.11 to 4.68]), witnessed aspiration (risk ratio, 3.25 [CI, 1.62 to 6.50]), and paralytic agents (risk ratio, 1.57 [CI, 1.03 to 2.39]). Exposure to antibiotics conferred protection (risk ratio, 0.37 [CI, 0.27 to 0.51]). Independent risk factors were the same regardless of the pneumonia definition used. CONCLUSIONS: The daily risk for pneumonia decreases with increasing duration of stay in the intensive care unit. Witnessed aspiration and exposure to paralytic agents are potentially modifiable independent risk factors. Exposure to antibiotics was associated with low rates of early ventilator-associated pneumonia, but this effect attenuates over time.

Adult↗
PubMed1998

Influence of airway management on ventilator-associated pneumonia: evidence from randomized trials.

OBJECTIVE: Ventilator-associated pneumonia (VAP) is a serious complication of critical illness, conferring increased morbidity and mortality. Many interventions have been studied to reduce the risk of VAP. We systematically reviewed the influence of airway management on VAP in critically ill patients. DATA SOURCES: Studies were identified through searching MEDLINE and EMBASE from 1980 through July 1997 and by searching SCISEARCH, the Cochrane Library, bibliographies of primary and review articles, personal files, and contact with authors of the randomized trials. STUDY SELECTION: We selected randomized trials evaluating ventilator circuit and secretion management strategies on the rate of VAP. DATA EXTRACTION: Two investigators independently abstracted key data on design features, the population, intervention, and outcome of the studies. DATA SYNTHESIS: The frequency of ventilator circuit changes and the type of endotracheal suction system do not appear to influence VAP rates (3 trials, none with significant difference; range of relative risks [RRs], 0.84-0.91). However, lower VAP rates may be associated with avoidance of heated humidifiers and use of heat and moisture exchangers (5 trials, only 1 showing a significant difference; range of RRs, 0.34-0.86), use of oral vs nasal intubation (1 trial; RR, 0.52; 95% confidence interval, 0.24-1.13), subglottic secretion drainage vs standard endotracheal tubes (2 trials, 1 showing a significant difference; range of RRs, 0.46-0.57), and kinetic vs conventional beds (5 trials, only 1 showing a significant difference; range of RRs, 0.35-0.78). CONCLUSIONS: Some ventilator circuit and secretion management strategies may influence VAP rates in critically ill patients. Whether these strategies are adopted in practice depends on several factors such as the magnitude and precision of estimates of benefit and harm, as well as access, availability, and costs.

Critical Illness↗
PubMed1998

Intensive care use in a developing country: a comparison between a Tunisian and a French unit.

OBJECTIVES: To compare the variations in intensive care (ICU) outcome in relation to variations in resources utilization and costs between a developed and a developing country with different medical and economical conditions. DESIGN AND SETTING: Prospective comparison between a 26-bed French ICU and an 8-bed Tunisian ICU, both in university hospitals. PATIENTS: Four hundred thirty and 534 consecutive admissions, respectively, in the French and Tunisian ICUs. MEASUREMENTS: We prospectively recorded demographic, physiologic, and treatment information for all patients, and collected data on the two ICU structures and facilities. Costs and ICU outcome were compared in the overall population, in three groups of severity indexes and among selected diagnostic groups. RESULTS: Tunisian patients were significantly younger, were in better health previously and were less severely ill at ICU admission (p < 0.01). French patients had a lower overall mortality rate (17.2 vs 22.5%; p < 0.01) and received more treatment (p < 0.01). In the low severity range, the outcome and costs were similar in the two countries. In the highest severity range, Tunisian and French patients had similar mortality rates, while the former received less therapy throughout their ICU stays (p < 0.05). Conversely, in the mid-range of severity, mortality was higher among Tunisian patients, and a difference in management was identified in COPD patients. CONCLUSION: Although the Tunisian ICU might appear more cost-effective than the French one in the highest severity group of patients, most of this difference appeared in relation to shorter lengths of ICU stay, and a poorer efficiency and cost-effectiveness was suggested in the mid-range severity group. Differences in economical constraints may partly explain differences in ICU performances. These results indicate where resource allocation could be directed to improve the efficiency of ICU care.

Adult↗
PubMed1998

Selective screening of carriers for control of methicillin-resistant Staphylococcus aureus (MRSA) in high-risk hospital areas with a high level of endemic MRSA.

Screening for methicillin-resistant Staphylococcus aureus (MRSA) carriage in patients at risk was evaluated as part of a control program in a 26-bed medical intensive care unit (ICU) of a university hospital with a high level of endemic MRSA. Control measures included isolation and barrier precautions, skin decolonization with chlorhexidine of patients from whom MRSA was recovered, and mupirocin treatment of nasal carriers of MRSA. Of 3,686 patients admitted during a 4-year period, 44% were screened, which occurred during admission for 38%; MRSA was recovered from 293 patients (8%). There were 150 imported cases and 143 ICU-acquired cases, of which 51% and 45%, respectively, were first identified through screening. Nasal swab cultures identified 84% of MRSA carriers. The incidence of all ICU-acquired cases and of acquired colonization or infection decreased from 5.8% and 5.6% to 2.6% and 1.4% (P = .002 and P < .001), respectively, whereas that of imported cases remained unchanged (range, 3.8% to 4.3%; P = .8). Selective screening for nasal carriage during admission to high-risk areas may contribute to identification of a substantial proportion of cases of MRSA and to early implementation of effective control measures.

Carrier State↗
PubMed1998

Treatment of ventilator-associated pneumonia with piperacillin-tazobactam/amikacin versus ceftazidime/amikacin: a multicenter, randomized controlled trial. VAP Study Group.

In a randomized trial conducted in 27 intensive care units, we compared the clinical efficacy and safety of piperacillin-tazobactam (TAZ; 4 g/0.5 g q.i.d.) and of ceftazidime (CAZ; 1 g q.i.d.), both combined with amikacin (7.5 mg/kg b.i.d.), as therapy for ventilator-associated pneumonia (VAP; acquired after > or =48 hours of mechanical ventilation). VAP was diagnosed with use of protected samples and quantitative cultures, and outcome was assessed blindly from treatment. Of 204 patients suspected of having VAP and randomized to a treatment arm of the study, 127 (64%) had bacteriologically confirmed infections, of which 37% were polymicrobial and 32% involved Pseudomonas aeruginosa; 115 patients (51 TAZ and 64 CAZ recipients) remained evaluable as per protocol. Clinical/bacteriologic cure rates (TAZ vs. CAZ, 51% vs. 36%; 95% confidence interval of difference, -0.2% to 30.2%), and 28-day mortality rates (16% vs. 20%) were similar; however, fewer bacteriologic failures occurred with TAZ (33% vs. 51%; P = .05). We conclude that the two regimens were of equivalent clinical efficacy in therapy for confirmed VAP.

Amikacin↗
PubMed1998

Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials.

OBJECTIVE: To evaluate the efficacy of tunneling short-term central venous catheters to prevent catheter-related infections. DATA SOURCES: MEDLINE, EMBASE, conference proceedings, citation review of relevant primary and review articles, personal files, and contact with expert informants. STUDY SELECTION: From a pool of 225 randomized, controlled trials of venous and arterial catheter management, we identified 12 relevant trials and included seven of these trials in the analysis. DATA EXTRACTION: In duplicate, independently, we abstracted data on the population, intervention, outcomes, and methodologic quality. DATA SYNTHESIS: Tunneling decreased bacterial colonization of the catheter by 39% (relative risk of 0.61; 95% confidence interval [CI] of 0.39 to 0.95) and decreased catheter-related sepsis with bacteriologic confirmation by 44% (relative risk of 0.56; 95% CI of 0.31 to 1) in comparison with standard placement. The majority of the benefit in the decreased rate of catheter-sepsis came from one trial at the internal jugular site (relative risk of 0.30, 95% CI of 0.10 to 0.89) and the reduction in risk was not significant when the data from five subclavian catheter trials were pooled (relative risk of 0.71, 95% CI of 0.36 to 1.43). Tunneling was not associated with increased risk of mechanical complications from placement or technical difficulties during placement. However, this outcome was not rigorously evaluated. CONCLUSIONS: Tunneling decreases central venous catheter-related infections. However, current evidence does not support routine tunneling until its efficacy is evaluated at different placement sites and relative to other interventions.

Bacteremia↗
PubMed1998

Protective effect of endotoxin instillation on subsequent bacteria-induced acute lung injury in rats.

The phagocytic capability afforded by neutrophil influx into the lungs is essential to ward off invading bacteria. The objective of this study was to evaluate the effect of prior neutrophil recruitment induced by alveolar instillation of endotoxin (LPS, 200 micrograms/kg) 16 h before a pulmonary infection caused by instillation of live Pseudomonas aeruginosa ([PYO]: 1.5 x 10(8) colony-forming units [cfu]/kg) in rats. A first series of experiments showed that lipopolysaccharide (LPS) instillation induced recruitment of alveolar neutrophils that were capable, ex vivo, of elastase exocytosis, reactive oxygen species secretion, and PYO killing. In a second set of experiments, LPS followed by PYO was compared with PYO alone (n = 11 surviving rats in each group). Parameters were studied 24 h after the bacterial challenge. As compared with PYO alone, pretreatment with LPS followed by PYO was associated with decreased mortality (0% versus 54%, p < 0.05), decreased protein leakage into bronchoalveolar lavage (BAL) fluid (1.8 +/- 0.4 versus 13.5 +/- 2.2 mg/ml, p < 0.001), and improved bacterial clearance from BAL (4.0 +/- 1.4 x 10(2) versus 1.2 +/- 0.5 x 10(4) cfu/ml, p < 0.05) and from pulmonary parenchyma (8.5 +/- 6.4 x 10(5) versus 1.9 +/- 0.8 x 10(7) cfu/ml, p < 0.05). We conclude that prior alveolar endotoxin instillation induces local recruitment of functionally active neutrophils, and that this is associated with resistance to subsequent experimental pneumonia.

Animals↗
PubMed1998

Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS.

Because animal studies have demonstrated that mechanical ventilation at high volume and pressure can be deleterious to the lungs, limitation of airway pressure, allowing hypercapnia if necessary, is already used for ventilation of acute respiratory distress syndrome (ARDS). Whether a systematic and more drastic reduction is necessary is debatable. A multicenter randomized study was undertaken to compare a strategy aimed at limiting the end-inspiratory plateau pressure to 25 cm H2O, using tidal volume (VT) below 10 ml/kg of body weight, versus a more conventional ventilatory approach (with regard to current practice) using VT at 10 ml/kg or above and close to normal PaCO2. Both arms used a similar level of positive end-expiratory pressure. A total of 116 patients with ARDS and no organ failure other than the lung were enrolled over 32 mo in 25 centers. The two groups were similar at inclusion. Patients in the two arms were ventilated with different VT (7.1 +/- 1.3 versus 10.3 +/- 1.7 ml/kg at Day 1, p < 0.001) and plateau pressures (25.7 +/- 5. 0 versus 31.7 +/- 6.6 cm H2O at Day 1, p < 0.001), resulting in different PaCO2 (59.5 +/- 15.0 versus 41.3 +/- 7.6 mm Hg, p < 0.001) and pH (7.28 +/- 0.09 versus 7.4 +/- 0.09, p < 0.001), but a similar level of oxygenation. The new approach did not reduce mortality at Day 60 (46.6% versus 37.9% in control subjects, p = 0.38), the duration of mechanical ventilation (23.1 +/- 20.2 versus 21.4 +/- 16. 3 d, p = 0.85), the incidence of pneumothorax (14% versus 12%, p = 0. 78), or the secondary occurrence of multiple organ failure (41% versus 41%, p = 1). We conclude that no benefit could be observed with reduced VT titrated to reach plateau pressures around 25 cm H2O compared with a more conventional approach in which normocapnia was achieved with plateau pressures already below 35 cm H2O.

Adolescent↗