Elie Azoulay

Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models

PurposeMethods for estimating the excess mortality attributable to ventilator-associated pneumonia (VAP) should handle VAP as a time-dependent covariate, since the probability of experiencing VAP increases with the time on mechanical ventilation. VAP-attributable mortality (VAP-AM) varies with definitions, case-mix, causative microorganisms, and treatment adequacy. Our objectives here were to compare VAP-AM estimates obtained using a traditional cohort analysis, a multistate progressive disability model, and a matched-cohort analysis; and to compare VAP-AM estimates according to VAP characteristics.MethodsWe used data from 2,873 mechanically ventilated patients in the Outcomerea® database. Among these patients from 12 intensive care units, 434 (15.1%) experienced VAP; of the remaining patients, 1,969 (68.5%) were discharged alive and 470 (16.4%) died. With the multistate model, VAP-AM was 8.1% (95% confidence interval [95%CI], 3.1–13.1%) for 120xa0days’ complete observation, compared to 10.4% (5.6–24.5%) using a matched-cohort approach (2,769 patients) with matching on mechanical ventilation duration followed by conditional logistic regression. VAP-AM was higher in surgical patients and patients with intermediate (but not high) Simplified Acute Physiologic Score II values at ICU admission. VAP-AM was significantly influenced by time to VAP but not by resistance of causative microorganisms. Higher Logistic Organ Dysfunction score at VAP onset dramatically increased VAP-AM (to 31.9% in patients with scores above 7).ConclusionA multistate model that appropriately handled VAP as a time-dependent event produced lower VAP-AM values than conditional logistic regression. VAP-AM varied widely with case-mix. Disease severity at VAP onset markedly influenced VAP-AM; this may contribute to the variability of previous estimates.

Efficacy of renal replacement therapy in critically ill patients: a propensity analysis

IntroductionAlthough renal replacement therapy (RRT) is a common procedure in critically ill patients with acute kidney injury (AKI), its efficacy remains uncertain. Patients who receive RRT usually have higher mortality rates than those who do not. However, many differences exist in severity patterns between patients with and those without RRT and available results are further confounded by treatment selection bias since no consensus on indications for RRT has been reached so far. Our aim was to account for these biases to accurately assess RRT efficacy, with special attention to RRT timing.MethodsWe performed a propensity analysis using data of the French longitudinal prospective multicenter Outcomerea database. Two propensity scores for RRT were built to match patients who received RRT to controls who did not despite having a close probability of receiving the procedure. AKI was defined according to RIFLE criteria. The association between RRT and hospital mortality was examined through multivariate conditional logistic regression analyses to control for residual confounding. Sensitivity analyses were conducted to examine the impact of RRT timing.ResultsAmong the 2846 study patients, 545 (19%) received RRT. Crude mortality rates were higher in patients with than in those without RRT (38% vs 17.5%, P < 0.001). After matching and adjustment, RRT was not associated with a reduced hospital mortality. The two propensity models yielded concordant results.ConclusionsIn our study population, RRT failed to reduce hospital mortality. This result emphasizes the need for randomized studies comparing RRT to conservative management in selected ICU patients, with special focus on RRT timing.

Year in review in Intensive Care Medicine, 2008: II. Experimental, acute respiratory failure and ARDS, mechanical ventilation and endotracheal intubation

Year in review in Intensive Care Medicine, 2008 : II. Experimental, acute respiratory failure and ARDS, mechanical ventilation and endotracheal intubation

Year in Review in Intensive Care Medicine, 2006. III. Circulation, ethics, cancer, outcome, education, nutrition, and pediatric and neonatal critical care.

Received: 22 January 2007Accepted: 22 January 2007Published online: 14 February 2007© Springer-Verlag 2007This review intends tosummarize all articlespublished in Intensive Care Medicine in2006, grouped by specific topicsP. AndrewsWestern General Hospital, Intensive CareMedicine Unit,Edinburgh, UKE. AzoulaySaint Louis Hospital, Intensive CareMedicine Unit,Paris, FranceM. AntonelliUniversita Cattolica del Sacre Cuore,Department of Intensive Care andAnesthesiology,Rome, ItalyL. Brochard (✉)AP-HP, Hopital Henri Mondor, UniversiteParis 12, Reanimation Medicale, INSERMU 651,94000 Creteil, Francee-mail: laurent.brochard@hmn.aphp.frTel.: +33-1-49812545Fax: +33-1-42079943C. Brun-BuissonAP-HP, Hopital Henri Mondor, UniversiteParis 12, Reanimation Medicale,Creteil, FranceD. De BackerErasme Hospital, Service des SoinsIntensifs,Brussels, BelgiumG. DobbRoyal Perth Hospital, Intensive CareMedicine Unit,Perth, AustraliaJ.-Y. FagonEuropean Georges Pompidou Hospital,Intensive Care Medicine Unit,H. GerlachVivantes-Klinikum Neukoelln, Departmentof Anesthesiology,Berlin, GermanyJ. GroeneveldVUMC, Intensive Care Medicine Unit,Amsterdam, The NetherlandsD. MacraeRoyal Brompton Hospital, PediatricIntensive Care Unit,London, UKJ. ManceboHospital Sant Pau, Intensive Care MedicineUnit,Barcelona, SpainP. MetnitzUniversity Hospital of Vienna, Departmentof Anesthesia and General Intensive CareMedicine,Vienna, AustriaS. NavaFondazione S. Maugeri, Intensive CareMedicine Unit,Pavia, ItalyJ. PuginUniversity Hospital of Geneva, IntensiveCare Medicine Unit,Geneva, SwitzerlandM. PinskyUniversity of Pittsburgh Medical Center,Intensive Care Medicine Unit,Pittsburgh Pennsylvania, USAP. RadermacherUniversity Medical School of Ulm,Department of Anesthesia,Ulm, GermanyC. RichardUniversity Hospital of Le Kremlin-Bicetre,Intensive Care Unit,Le Kremlin-Bicetre, France

Post-ICU discharge and outcome: rationale and methods of the The French and euRopean Outcome reGistry in Intensive Care Units (FROG-ICU) observational study

BackgroundPrevious studies have demonstrated that ICU (intensive care unit) survivors have decreased long-term survival rates compared to the general population. However, knowledge about how to identify ICU survivors with higher risk of death and the adjustable factors associated with mortality is still lacking.Methods and DesignThe FROG-ICU (the French and European Outcome Registry in Intensive Care Units) study is a prospective, observational, multicenter cohort study where ICU survivors are followed up to one year after ICU discharge. Beside one year survival, the study is designed to assess incidence and identifying risk factors for mortality over the year following discharge from the ICU. All consecutive patients admitted in ICU to the 28 participating centers during the study period will be included. Every subject will undergo an evaluation at admission, throughout the ICU stay and at ICU discharge. The global, especially cardiovascular, assessment of each subject will be performed through a complete clinical exam, instrumental tests (electrocardiogram, echocardiogram) and biological parameters. Blood and urine samples will be collected at admission and at discharge with the primary goal to assess effectiveness of routine and novel cardiovascular, inflammatory and renal biomarkers, with potential interest in risk stratification for patients who survive an ICU stay. The follow up will include a careful tracking of patients through telephone calls and questionnaires at 3, 6 and 12xa0months after ICU discharge. FROG-ICU aims to identify the clinical and biological phenotype of patients with different levels of probability of death in the year after ICU discharge.DiscussionFROG-ICU has been designed to better understand long term outcome after ICU discharge as well as risk factors for all-cause and cardiovascular morbidity and associated mortality. It is a large prospective multicenter cohort with a biological (on plasma and urine) collection and one-year follow-up of ICU patients. FROG ICU will allow performing a risk stratification of ICU survivors as to recognize the subset of patients who may benefit from an early intervention to allow decreased cardiovascular morbidity and related mortality.Trial registrationClinicalTrials.gov NCT01367093.

Year in review in Intensive Care Medicine, 2006. I. Experimental studies. Clinical studies: brain injury, renal failure and endocrinology

Peter Andrews Elie Azoulay Massimo Antonelli Laurent Brochard Christian Brun-Buisson Daniel De Backer Geoffrey Dobb Jean-Yves Fagon Herwig Gerlach Johan Groeneveld Duncan Macrae Jordi Mancebo Philipp Metnitz Stefano Nava Jerôme Pugin Michael Pinsky Peter Radermacher Christian Richard Year in review in Intensive Care Medicine, 2006. I. Experimental studies. Clinical studies: brain injury, renal failure and endocrinology

Year in review in Intensive Care Medicine, 2007. III. Ethics and legislation, health services research, pharmacology and toxicology, nutrition and paediatrics.

Year in review in Intensive Care Medicine, 2007. III. Ethics and legislation, health services research, pharmacology and toxicology, nutrition and paediatrics

Year in review in Intensive Care Medicine, 2008 : III. Paediatrics, Ethics, outcome research and critical care organization, sedation, pharmacology and miscellanea

Year in review in Intensive Care Medicine, 2008 : III. Paediatrics, Ethics, outcome research and critical care organization, sedation, pharmacology and miscellanea

Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome

Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome

Year in review in Intensive Care Medicine, 2007. I. Experimental studies. Clinical studies : brain injury and neurology, renal failure and endocrinology

Year in review in Intensive Care Medicine, 2007. I. Experimental studies. Clinical studies : brain injury and neurology, renal failure and endocrinology