Moussa Cisse

The measurement of pain in intensive care unit: Comparison of 5 self-report intensity scales

&NA; Unlike wards, where chronic and acute pain are regularly managed, comparisons of the most commonly used self‐report pain tools have not been reported for the intensive care unit (ICU) setting. The objective of this study was to compare the feasibility, validity and performance of the Visual Analog Scale (horizontal (VAS‐H) and vertical (VAS‐V) line orientation), the Verbal Descriptor Scale (VDS), the 0–10 oral Numeric Rating Scale (NRS‐O) and the 0–10 visually enlarged laminated NRS (NRS‐V) for pain assessment in critically ill patients. One hundred and eleven consecutive patients admitted into a medical‐surgical ICU were included as soon as they became alert and were able to follow simple commands. Pain was measured using the 5 scales in a randomized order upon enrollment‐(T1) and after‐(T2) administration of an analgesic or, in absence of pain upon enrollment, after a nociceptive procedure. The rate of any response obtained both at T1 and T2 (success rate) was significantly higher for NRS‐V (91%) compared with NRS‐O (83%), VDS (78%), VAS‐H (68%) and VAS‐V (66%). Pain intensity changed significantly between T1 and T2, showing a good validity and responsiveness for the 5 scales, which correlated well between each other. The negative predictive value calculated from true and false negatives defined by real and false absence of pain was highest for NRS‐V (90%). In conclusion, the NRS‐V should be the tool of choice for the ICU setting, because it is the most feasible and discriminative self‐report scale for measuring critically ill patients’ pain intensity.

Analgesic efficacy and haemodynamic effects of nefopam in critically ill patients

BACKGROUND Pain management is challenging in intensive care unit (ICU) patients. The analgesic efficacy, tolerance, and haemodynamic effects of nefopam have never been described in critically ill patients. METHODS In consecutive medical-surgical ICU patients who received 20 mg of nefopam i.v. over 30 min, we measured pain, Richmond Agitation Sedation Scale (RASS), respiratory parameters, and adverse drug events at T0 (baseline), T30 (end-of-infusion), T60, and T90 min. Haemodynamic variables were assessed every 15 min from T0 to T60 and T90. Pain was evaluated by the behavioural pain scale (BPS, 3-12) or by the self-reported visual numeric rating scale (NRS, 0-10) according to communication capacity. RESULTS Data were analysed for 59 patients. As early as T30, median NRS and BPS decreased significantly from T0 to a minimum level at T60 for NRS [5 (4-7) vs 1 (1-3), P<0.001] and T90 for BPS [5 (5-6) vs 3 (3-4), P<0.001]. No significant changes were detected for RASS, ventilatory frequency, or oxygen saturation. Increased heart rate and decreased mean arterial pressure, defined as a change ≥15% from baseline, were found in 29% and 27% of patients, respectively. For the 18 patients monitored, cardiac output increased by 19 (7-29)% and systemic vascular resistance decreased by 20 (8-28)%, both maximally at T30. Heat sensation, nausea/vomiting, sweating, and mouth dryness were found, respectively, in 6%, 9%, 22%, and 38% of patients. CONCLUSIONS A single slow infusion of nefopam is effective in critically ill patients who have moderate pain. The risk of tachycardia and increased cardiac output and also hypotension and decreased systemic vascular resistance should be known to evaluate the benefit/risk ratio of its prescription.

R2: The Absence of Adrenal Gland Enlargement during Septic Shock Predicts Mortality: A Computed Tomography Study of 239 Patients

Background:Assessment and management of septic shock associated adrenal function remain controversial. The aim of this study was to explore the prognostic value of adrenal gland volume in adults with septic shock. Methods:A short cosyntropin test and determination of adrenal volume by computed tomography were performed within 48 h of shock in patients with septic shock (n = 184) and in 2 control groups: 40 ambulatory patients and 15 nonseptic critically ill patients. The primary endpoint was intensive care unit mortality. Results:At intensive care unit discharge, 59 patients with septic shock died. Adrenal volume was 12.5 cm3 [95% CI, 11.3–13.3] and 8 cm3 [95% CI, 6.8–10.1] in the nonseptic group (P < 0.05 with both septic cohorts) and 7.2 cm3 [95%CI, 6.3–8.5] in the ambulatory patient group (P < 0.05 in patients with septic shock). In patients with septic shock, adrenal volume less than 10 cm3 was associated with higher 28-day mortality rates with an area under the receiver operating curve of 0.84 [95% CI, 0.78–0.89]. Adrenal volume above 10 cm3 was an independent predictor of intensive care unit survival (hazard ratio = 0.014; 95% CI [0.004–0.335]). Conclusion:A total adrenal gland volume less than 10 cm3 during septic shock was associated in univariate and multivariate analysis with mortality at day 28 in patients with septic shock. Whether adrenal gland volume can be a surrogate of adrenal gland function and used to guide hydrocortisone therapy in septic shock patients needs to be further investigated.

Epidemiology and Burden of Bloodstream Infections Caused by Extended-Spectrum Beta-Lactamase Producing Enterobacteriaceae in a Pediatric Hospital in Senegal

Context Severe bacterial infections are not considered as a leading cause of death in young children in sub-Saharan Africa. The worldwide emergence of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-E) could change the paradigm, especially in neonates who are at high risk of developing healthcare-associated infections. Objective To evaluate the epidemiology and the burden of ESBL-E bloodstream infections (BSI). Methods A case-case-control study was conducted in patients admitted in a pediatric hospital during two consecutive years. Cases were patients with Enterobacteriaceae BSI and included ESBL-positive (cases 1) and ESBL-negative BSI (cases 2). Controls were patients with no BSI. Multivariate analysis using a stepwise logistic regression was performed to identify risk factors for ESBL acquisition and for fatal outcomes. A multistate model was used to estimate the excess length of hospital stay (LOS) attributable to ESBL production while accounting for time of infection. Cox proportional hazards models were performed to assess the independent effect of ESBL-positive and negative BSI on LOS. Results The incidence rate of ESBL-E BSI was of 1.52 cases/1000 patient-days (95% CI: 1.2–5.6 cases per 1000 patient-days). Multivariate analysis showed that independent risk factors for ESBL-BSI acquisition were related to underlying comorbidities (sickle cell disease OR = 3.1 (95%CI: 2.3–4.9), malnutrition OR = 2.0 (95%CI: 1.7–2.6)) and invasive procedures (mechanical ventilation OR = 3.5 (95%CI: 2.7–5.3)). Neonates were also identified to be at risk for ESBL-E BSI. Inadequate initial antibiotic therapy was more frequent in ESBL-positive BSI than ESBL-negative BSI (94.2% versus 5.7%, p<0.0001). ESBL-positive BSI was associated with higher case-fatality rate than ESBL-negative BSI (54.8% versus 15.4%, p<0.001). Multistate modelling indicated an excess LOS attributable to ESBL production of 4.3 days. The adjusted end-of-LOS hazard ratio for ESBL-positive BSI was 0.07 (95%CI, 0.04–0.12). Conclusion Control of ESBL-E spread is an emergency in pediatric populations and could be achieved with simple cost-effective measures such as hand hygiene, proper management of excreta and better stewardship of antibiotic use, especially for empirical therapy.

Épidémiologie, pronostic et complications infectieuses nosocomiales des pancréatites aiguës graves en réanimation : étude prospective multicentrique à partir de la base de données CClin Sud-Est

OBJECTIVES To describe the demographic characteristics, incidence of extra-abdominal hospital-acquired infections and outcome of patients admitted to intensive care unit (ICU) with severe acute pancreatitis. STUDY DESIGN A retrospective, observational multiple center (65 centers) analysis of prospectively acquired data. PATIENTS AND METHODS During 2 years, all consecutive admitted patients to ICU for severe acute pancreatitis in the centers participating in the nosocomial infections surveillance network CClin Sud-Est were included. Patients whose ICU stay was less than 48 hours were not included. Demographic characteristics, extra-abdominal hospital-acquired infections and clinical course were described. RESULTS During the study period, 510 patients were included which represented 2 % of patients with a length of stay longer than 48 hours in the 65 participating ICUs. The global attack rate of extra-abdominal hospital-acquired infections (pneumonia, bacteremia, urinary tract or central venous catheter infection) was 23 % in overall patients and it was 33 % in the 294 mechanically ventilated patients. ICU mortality was 20 % in overall patients and it was 34 % in mechanically ventilated patients. CONCLUSION Severe acute pancreatitis represents 2 % of ICU stay longer than 48 hours. Its clinical course is frequently complicated by hospital-acquired infections and is associated with an high ICU mortality rate. This epidemiological observational study may be used for calculating sample size for future multicenter interventional therapeutic studies.

Expérience de l’utilisation de la tigécycline dans le traitement des infections sévères en réanimation : une étude pilote

OBJECTIVES To report our experience of tigecycline use in a medical and surgical intensive care unit. To describe its prescription, microbiology findings, tolerance and efficacy. STUDY DESIGN Prospective, observational, single center study. PATIENTS AND METHODS All consecutive patients treated with tigecycline were included. Demography, indication of treatment, bacteriology before, during and in the month after treatment and ICU mortality were collected. The main endpoints were clinical and microbiological efficacy and tolerance. RESULTS Twenty-four patients were included. In half of the cases, tigecycline was prescribed in monotherapy for a complicated intra-abdominal infection. Overall tolerance of tigecycline was good. Clinical and microbiological cure was obtained in six cases, not obtained in nine, indeterminate in six cases and not evaluable in the three cases of prophylaxis. During the treatment, four bacteria commonly sensitives were shown to be resistant to tigecycline. CONCLUSION Our pilot study on 24 patients suggests that tigecycline is well tolerated in critically ill patients. Clinical cure in severe infections was compromised in nine patients essentially because of resistant pathogens suggesting its prescription on antibiogram. However, the impact of association or the increasing doses in severe critically ill patients should be evaluated.

Impact of rotavirus vaccine on acute gastroenteritis in children under 5 years in Senegal: Experience of sentinel site of the Albert Royer Children's Hospital in Dakar

BACKGROUND Acute gastroenteritis (AGE) is a leading cause of morbidity and mortality among children <5 years of age in developing countries, with rotavirus being the most common infectious etiology. In November 2014, monovalent rotavirus vaccine was introduced in Senegal. We determined the impact of rotavirus vaccine on hospitalizations for all-cause and rotavirus related AGE in children <60 months of age. METHODS We examined two data sources from the national referral hospital. Using sentinel surveillance data from March 2011 to February 2017, we examined the proportion of AGE hospitalizations among children <60 months of age attributable to rotavirus, stratified by age groups (0-11, 12-23 and 24-59 months). Using pediatric logbook data from March 2010 to February 2017, we examined the proportion of all childhood hospitalizations attributable to AGE, among the same age groups. RESULTS In sentinel surveillance, 673 patients <60 months were hospitalized for AGE, with 30% (203/673) due to rotavirus. In pre-vaccine years, the median proportion of rotavirus-positive hospitalizations was 42%; this proportion declined by 76% to 10% rotavirus positive in 2015-2016 (p < .001) and by 59% to 17% in 2016-2017 (p < .001). From the logbook data, among all children <60 months, a median of 11% of all hospitalizations in the pre-vaccine period were due to AGE, with 2015-2016 seeing a 16% decline (p < .001), to 9% of all hospitalizations, and 2016-2017 seeing a 39% decline (p < .001), to 7% of all hospitalizations. Declines in both rotavirus-associated and all-cause AGE hospitalizations were most marked among infants, with a suggestion of herd effect among older children seen in the surveillance data. CONCLUSION Rotavirus vaccine demonstrated a significant impact on rotavirus-associated hospitalizations and all-cause AGE hospitalizations in the first two seasons after vaccine introduction in Senegal. Our data support the continued use of this vaccine in national immunization program.

Intérêt du masque laryngé renforcé au cours de la chirurgie réparatrice chez les patients brûlés nécessitant une mobilisation de la tête : étude de faisabilité

OBJECTIVE To evaluate the feasibility and reliability of the flexible laryngeal mask airway (LMA flexible) use during scalp skin harvesting for surgical reparation of burn sequella. STUDY DESIGN Observational prospective descriptive study. PATIENTS AND METHODS Following local ethic committee approval, 26 patients were included in the study during their preanaesthesia visit. The general anaesthesia induction of each patient was followed by the insertion of a LMA flexible. The number of attempts required to insert the mask and the procedure were documented. The oropharyngeal leak pressure, expired tidal volume and end tidal CO(2) were recorded in five different head positions (neutral, hyperflexion, hyperextension, right and left rotation) at the start and end of surgical procedure. In all ten study periods of 2-3 min each were evaluated. RESULTS The airway device was inserted easily in all patients. While similar in four of the five head positions (neutral: 27.9+/-8.1 cmH(2)O, hyperextension, left and right rotation), the oropharyngeal leak pressure was significantly higher in the hyperflexion position (33.3+/-7.3 cmH(2)O). The end tidal volume was stable in all positions except hyperflexion (419+/-114 ml). While this value was significantly lower than the 471+/-68 ml recorded in the neutral position, it remained greater than 7 ml/kg. No significant change was observed for end tidal CO(2) for the ten study periods. CONCLUSION The use of LMA flexible during surgical burn repair procedures, including head mobilisation for the harvesting of scalp skin grafts is feasible.