Naoufel Madani

Eosinopenia is a reliable marker of sepsis on admission to medical intensive care units

IntroductionEosinopenia is a cheap and forgotten marker of acute infection that has not been evaluated previously in intensive care units (ICUs). The aim of the present study was to test the value of eosinopenia in the diagnosis of sepsis in patients admitted to ICUs.MethodsA prospective study of consecutive adult patients admitted to a 12-bed medical ICU was performed. Eosinophils were measured at ICU admission. Two intensivists blinded to the eosinophils classified patients as negative or with systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, or septic shock.ResultsA total of 177 patients were enrolled. In discriminating noninfected (negative + SIRS) and infected (sepsis + severe sepsis + septic shock) groups, the area under the receiver operating characteristic curve was 0.89 (95% confidence interval (CI), 0.83 to 0.94). Eosinophils at <50 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 91% (95% CI, 79% to 96%), a positive likelihood ratio of 9.12 (95% CI, 3.9 to 21), and a negative likelihood ratio of 0.21(95% CI, 0.15 to 0.31). In discriminating SIRS and infected groups, the area under the receiver operating characteristic curve was 0.84 (95% CI, 0.74 to 0.94). Eosinophils at <40 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 80% (95% CI, 55% to 93%), a positive likelihood ratio of 4 (95% CI, 1.65 to 9.65), and a negative likelihood ratio of 0.25 (95% CI, 0.17 to 0.36).ConclusionEosinopenia is a good diagnostic marker in distinguishing between noninfection and infection, but is a moderate marker in discriminating between SIRS and infection in newly admitted critically ill patients. Eosinopenia may become a helpful clinical tool in ICU practices.

Incidence, étiologies et facteurs pronostiques de l'hyponatrémie en réanimation

Purpose. – The incidence of hyponatremia is unknown, their causes are multiple. The higher mortality, especially in intensive care units, is currently unexplained. The objective of this article is to evaluate the incidence of hyponatremia, to assess their causes and to identify predictors of prognosis in intensive care units. Methods. – We included retrospectively all patients admitted at department of medical intensive care unit between January 1996 and February 2001, who presented at the admission, an hyponatremia ( 13 mmol/l or with mannitol administration. Data were analysed by univariate methods, then by multivariate analysis. Results. – During the study period, 300 patients were identified among 2188: the incidence was 13.7% with 95% confidence interval (95% CI) between 9.8 % and 16.7%. Hypovolemic hyponatremia was observed in 25.7%, hypervolemic in 23.7% and normovolemic in 50.6%. In-hospital mortality was 37.7% (95% CI: 31.8% – 42.3%). Nine data were significantly associated with higher mortality in univariate analysis, but only 5 were identified as independant predictors of hospital mortality in multivariate analysis: hyponatremia 10 mmol/l (RR = 1.59; 95% CI : 1.08–2.34; p = 0.02). Conclusion. – The frequency of hyponatremia is high ; the normovolemic type represented 50%. Mortality is linked, in greater part, to organs dysfunction, but the severity of hyponatremia remained a significant predictor of mortality.

Health-care associated infections rates, length of stay, and bacterial resistance in an intensive care unit of Morocco: findings of the International Nosocomial Infection Control Consortium (INICC).

Background Most studies related to healthcare-associated infection (HAI) were conducted in the developed countries. We sought to determine healthcare-associated infection rates, microbiological profile, bacterial resistance, length of stay (LOS), and extra mortality in one ICU of a hospital member of the International Infection Control Consortium (INICC) in Morocco. Methods We conducted prospective surveillance from 11/2004 to 4/2008 of HAI and determined monthly rates of central vascular catheter-associated bloodstream infection (CVC-BSI), catheter-associated urinary tract infection (CAUTI) and ventilator-associated pneumonia (VAP). CDC-NNIS definitions were applied. device-utilization rates were calculated by dividing the total number of device-days by the total number of patient-days. Rates of VAP, CVC-BSI, and CAUTI per 1000 Device-days were calculated by dividing the total number of HAI by the total number of specific Device-days and multiplying the result by 1000. Results 1,731 patients hospitalized for 11,297 days acquired 251 HAIs, an overall rate of 14.5%, and 22.22 HAIs per 1,000 ICU-days. The central venous catheter-related bloodstream infections (CVC-BSI) rate found was 15.7 per 1000 catheter-days; the ventilator-associated pneumonia (VAP) rate found was 43.2 per 1,000 ventilator-days; and the catheter-associated urinary tract infections (CAUTI) rate found was 11.7 per 1,000 catheter-days. Overall 25.5% of all Staphylococcus aureus HAIs were caused by methicillin-resistant strains, 78.3% of Coagulase-negative-staphylococci were methicillin resistant as well. 75.0% of Klebsiella were resistant to ceftriaxone and 69.5% to ceftazidime. 31.9% of E. Coli were resistant to ceftriaxone and 21.7% to ceftazidime. 68.4% of Enterobacter sp were resistant to ceftriaxone, 55.6% to ceftazidime, and 10% to imipenem; 35.6% of Pseudomonas sp were resistant to ceftazidime and 13.5% to imipenem. LOS of patients was 5.1 days for those without HAI, 9.0 days for those with CVC-BSI, 10.6 days for those with VAP, and 13.7 days for those with CAUTI. Extra mortality was 56.7% (RR, 3.28; P =< 0.001) for VAP, 75.1% (RR, 4.02; P = 0.0027) for CVC-BSI, and 18.7% (RR, 1.75; P = 0.0218) for CAUTI. Conclusion HAI rates, LOS, mortality, and bacterial resistance were high. Even if data may not reflect accurately the clinical setting of the country, programs including surveillance, infection control, and antibiotic policy are a priority in Morocco.

Weaning from mechanical ventilation: a model for extubation

Objective: To develop a model able to determine the right time for extubation and to validate its performance.¶Design: A prospective clinical study.¶Setting: 14-bed medical intensive care unit in a university hospital.¶Patients: 101 patients (37 women/64 men) ventilated over more than 48 h (mean 10.4 ± 10.3 days) and considered ready to be weaned by the medical team (February 1996–February 1998).¶Methods: This study included two series: a development series with 53 patients and a validation series with 48 patients. Before extubation, a weaning test was performed measuring tidal volume (VT), respiratory rate (f), f/VT ratio, minute ventilation, vital capacity (VC) and maximum inspiratory and expiratory pressures (MIP and MEP). The success of extubation was assessed after 48 h. Receiver operating characteristic (ROC) curves allowed the analysis of the discriminating power of each parameter. Threshold values were determined using the Youdens index. To create the best predictive model, we performed a multiple logistic regression analysis. To assess the calibration and the discrimination of the model, the Hosmer-¶Lemeshow goodness-of-fit test and area under ROC curves (AUC) were adopted.¶Measurements and results: In a development series, 60 tests were carried out with 38 successful extubations and 22 extubation failures. The multivariate analysis found three significant variables: VC (threshold value = 635 ml), f/VT ratio (threshold value = 88 breaths/min.l) and MEP (threshold value = 28 cmH2O). The validation cohort included 59 tests (38 successes and 21 failures). The validation series shows a good discrimination (AUC = 0.855 ± 0.059) and calibration (goodness-of-fit test C: p = 0.224) of the model.¶Conclusion: VC together with the ¶f/VT ratio and MEP offer accurate prediction of early extubation.

Measurement properties of the Short Form 36 and health-related quality of life after intensive care in Morocco

Background:  Intensive care patients have a health‐related quality of life (HRQL) that differs from the normal population. The aim of this study was to evaluate the measurement properties of the Arabic version of the short form (SF)‐36 and study the HRQL determinants in adult patients 3 months after discharge from an intensive care unit (ICU).

Measuring the satisfaction of intensive care unit patient families in Morocco: a regression tree analysis.

Objective:Meeting the needs of patients’ family members becomes an essential part of responsibilities of intensive care unit physicians. The aim of this study was to evaluate the satisfaction of patients’ family members using the Arabic version of the Society of Critical Care Medicine’s Family Needs Assessment questionnaire and to assess the predictors of family satisfaction using the classification and regression tree method. Design:The authors conducted a prospective study. Setting:This study was conducted at a 12-bed medical intensive care unit in Morocco. Patients:Family representatives (n = 194) of consecutive patients with a length of stay >48 hrs were included in the study. Intervention:Intervention was the Society of Critical Care Medicine’s Family Needs Assessment questionnaire. Measurements and Main Results:Demographic data for relatives included age, gender, relationship with patients, education level, and intensive care unit commuting time. Clinical data for patients included age, gender, diagnoses, intensive care unit length of stay, Acute Physiology and Chronic Health Evaluation, MacCabe index, Therapeutic Interventioning Scoring System, and mechanical ventilation. The Arabic version of the Society of Critical Care Medicine’s Family Needs Assessment questionnaire was administered between the third and fifth days after admission. Of family representatives, 81% declared being satisfied with information provided by physicians, 27% would like more information about the diagnosis, 30% about prognosis, and 45% about treatment. In univariate analysis, family satisfaction (small Society of Critical Care Medicine’s Family Needs Assessment questionnaire score) increased with a lower family education level (p = .005), when the information was given by a senior physician (p = .014), and when the Society of Critical Care Medicine’s Family Needs Assessment questionnaire was administered by an investigator (p = .002). Multivariate analysis (classification and regression tree) showed that the education level was the predominant factor contributing to the Society of Critical Care Medicine’s Family Needs Assessment questionnaire score. Society of Critical Care Medicine’s Family Needs Assessment questionnaire increased (greater satisfaction) with a higher education level. Other factors of great satisfaction included the senior physician providing the information, and Acute Physiology and Chronic Health Evaluation <15. Conclusions:Satisfaction of intensive care unit patients’ families in a Moroccan sample using the classification and regression tree was dependent on relatives’ education level, communication presented by senior caregiver, and low Acute Physiology and Chronic Health Evaluation score. These data underline cultural specificities of the study and suggest that caregivers should develop structured communication programs considering satisfaction predictors.

Incidence of medication errors in a Moroccan medical intensive care unit

Background Medication errors (ME) are an important problem in all hospitalized populations, especially in intensive care unit (ICU). The aim of the study was to determine incidence, type and consequences of ME. Materials and methods Prospective observational cohort study during six weeks in a Moroccan ICU. Were included all patients admitted for > 24 hours. ME were collected by two reviewers following three methods: voluntary and verbally report by medical and paramedical staff, chart review and studying prescriptions and transcriptions. Seriousness of events was classified from Category A: circumstances or events that have the capacity to cause error, to Category I: patients death. Results 63 patients were eligible with a total of 509 patient-days, and 4942 prescription. We found 492 ME, which incidence was 10 per 100 orders and 967 per 1000 patient-days. There were 113 potential Adverse Drug Events (ADEs) [2.28 per 100 orders and 222 per 1000 patient-days] and 8 ADEs [0.16 per 100 orders and 15.7 per 1000 patient-days]. MEs occurred in transcribing stage in 60%cases. Antibiotics were the drug category in 33%. Two ADEs conducted to death. Conclusion MEs are common in Moroccan medical ICU. These results suggest future targets of prevention strategies to reduce the rate of ME.

Withholding and withdrawing life-sustaining therapy in a Moroccan Emergency Department: An observational study

BackgroundWithdrawing and withholding life-support therapy (WH/WD) are undeniably integrated parts of medical activity. However, Emergency Department (ED) might not be the most appropriate place to give end-of life (EOL) care; the legal aspects and practices of the EOL care in emergency rooms are rarely mentioned in the medical literature and should be studied. The aims of this study were to assess frequency of situations where life-support therapies were withheld or withdrawn and modalities for implement of these decisions.MethodA survey of patients who died in a Moroccan ED was performed. Confounding variables examined were: Age, gender, chronic underlying diseases, acute medical disorders, APACHE II score, Charlson Comorbidities Index, and Length of stay. If a decision of WH/WD was taken, additional data were collected: Type of decision; reasons supporting the decision, modalities of WH/WD, moment, time from ED admission to decision, and time from processing to withhold or withdrawal life-sustaining treatment to death. Individuals who initiated (single emergency physician, medical staff), and were involved in the decision (nursing staff, patients, and families), and documentation of the decision in the medical record.Results177 patients who died in ED between November 2009 and March 2010 were included. Withholding and withdrawing life-sustaining treatment was applied to 30.5% of all patients who died. Therapies were withheld in 24.2% and were withdrawn in 6.2%. The most reasons for making these decisions were; absence of improvement following a period of active treatment (61.1%), and expected irreversibility of acute disorder in the first 24 h (42.6%). The most common modalities withheld or withdrawn life-support therapy were mechanical ventilation (17%), vasopressor and inotrops infusion (15.8%). Factors associated with WH/WD decisions were older age (OR = 1.1; 95%IC = 1.01-1.07; P = 0.001), neurological acute medical disorders (OR = 4.1; 95%IC = 1.48-11.68; P = 0.007), malignancy (OR = 7.7; 95%IC = 1.38-8.54; P = 0.002) and cardiovascular (OR = 3.4;95%IC = 2.06-28.5;P = 0.008) chronic underlying diseases.ConclusionLife-sustaining treatment were frequently withheld or withdrawn from elderly patients with underlying chronic cardiovascular disease or metastatic cancer or patients with acute neurological medical disorders in a Moroccan ED. Religious beliefs and the lack of guidelines and official Moroccan laws could explain the ethical limitations of the decision-making process recorded in this study.

Patient satisfaction in a Moroccan emergency department

Background Measuring healthcare quality and improving patient satisfaction have become increasingly prevalent, especially among healthcare providers and purchasers of healthcare. Currently, research is interested to the satisfaction in several areas, and in various cultures. The aim of this study was; to confirm the reliability and validity of the Arabic version of the Emergency Department Quality Study (EDQS), to evaluate patient satisfaction with emergency care, and to determine associated factors with patient satisfaction. Methods A survey of socio demographic, visit and health characteristics of patients, conducted in emergency department (ED) of a Moroccan University Hospital during 1 week in February 2009. The EDQS was performed with patients who were discharged from ED. The psychometric properties of the EDQS were tested. Factors influencing patient satisfaction were identified using ordinal logistic regression. Results A total of 212 patients were enrolled. The Arabic version of the EDQS showed excellent reliability and validity. Sixty six percent of participants were satisfied with overall care, and 69.8% would return to our unit. The most patient-reported problems were about waiting time and test results. Variables associated with greater satisfaction with ED care were: emergent (OR: 0.15; 95% CI = 0.04-0.31; P < 0.001), or urgent patients (OR: 0.35; 95% CI = 0.15-0.86; P = 0.02) compared to non-urgent patients, and waiting time less than 15 min (OR: 0.41; 95% CI = 0.23-0.75; P = 0.003). Variables associated with lesser satisfaction were: distance patient’s home hospital ≤10Kilometers (OR: 2.64; 95% CI = 1.53-4.53; P < 0.001), weekday’s admissions (OR: 2.66; 95% CI = 1.32 to 5.34; P < 0.006), and educational level; with secondary (OR: 5.19; 95% CI = 2.04-13.21; P < 0.001) primary (OR: 3.04; 95% CI = 1.10-8.04; P = 0.03) and illiterate patients (OR: 2.53; 95% CI = 1.02-6.30; P = 0.03) were less satisfied compared to those with high educational level. Conclusion Medical staff needs to consider different interactions between those predictive factors in order to develop some supportive tools.

Factors predicting mortality in elderly patients admitted to a Moroccan medical intensive care unit

Introduction. There has been a notable increase in the incidence of elderly patients being admitted to intensive care units (ICUs), globally and in Morocco. Studies on the diagnosis and management of ICU patients often exclude subjects with multiple co-morbidities or those older than 80 years. However, as the world’s population becomes increasingly old and ill, this subset will require ICU admission more frequently and their management will pose a serious challenge to the intensivists treating them. There are no studies in the current medical literature from low- or middle-income countries assessing the outcome of elderly patients admitted to ICUs. Specifically, little is known about the outcome of elderly patients admitted to ICUs in Morocco. Aims. The aims of the present study were to analyse the characteristics of elderly Moroccan patients (aged ≥65 years) admitted to a medical ICU, and to identify factors predicting ICU mortality. Methods. This was a retrospective study conducted in the medical ICU of a Moroccan university hospital. All elderly patients (≥65 years) with complete records were included, whatever their length of stay. Baseline characteristics, clinical parameters and severity of illness were recorded at admission. Patients were grouped according to their survival status using logistic regression analysis. Results. During the study period, 1 072 patients were admitted to the ICU, of whom 16.6% (n=179) were older than 65 and had complete records. Fifty-five per cent (n=98) were men. The median age was 70 years (interquartile range 67 - 75 years). The overall ICU mortality was 44.7%, and 64% of deaths occurred in the first 5 days after admission. On univariate analysis, the factors predicting mortality were alcohol misuse (p=0.09), pneumonia (p≤0.001), shock (p=0.001), dehydration (p=0.007), urine output ≤0.5 ml/kg/h (p =0.003), serum urea level >16.6 mmol/l (p=0.01), serum creatinine level >159 µmol/l (p=0.005), and an abnormality on the chest radiograph (p=0.01). The Sequential Organ Failure Assessment (SOFA) score was the most accurate predictor of ICU mortality in this group of elderly patients, with an area under the curve (AUC) of 0.775 (standard deviation (SD) ±0.036). The Acute Physiology and Chronic Health Evaluation II (APACHE II) score also performed adequately (AUC 0.757; SD ±0.037), but the Simplified Acute Physiology Score II (SAPS II) and Logistic Organ Dysfunction System (LODS) scores were not useful in this group. Two parameters significantly associated with mortality risk were shock (odds ratio (OR) 11.5, 95% confidence interval (CI) 3.7 - 35.7; p<0.001) and pneumonia (OR 3.13, 95% CI 1.5 - 6.2; p<0.001). Conclusion. Admission of aged patients to the ICU raises important medical, ethical, sociological and economic questions. Our findings suggest that severity of illness, shock and pneumonia on ICU admission were the independent risk factors associated with raised mortality, 64% of which occurred during the 5 days after ICU admission.