Anaesthesia Critical Care & Pain Medicine最新文献

Context: In European and Anglo-Saxon countries, life-sustaining treatment (LST) limitation decisions precede more than 80% of ICU deaths. However, there is now increasing evidence of disagreement and conflict between clinical teams and family members over LST limitation decisions. In some cases, these conflicts are brought to the courts. The aim of this study was to provide a descriptive and qualitative analysis of cases brought to the French courts.

Methods: We conducted a retrospective national observational study. All identified cases of emergency recourse to the judge in the context of LST limitation decisions in France between 2005 and 2022 were included.

Results: Seventy-six cases were investigated by the judge, with an increasing number over the years. The LST limitation decisions contested by the relatives were mainly decisions to withdraw treatment (78%) concerning patients with neurological injury (76%). The judge successively assessed the compliance with the legal decision-making process and the characterization of the inappropriateness of treatments. The latter was assessed by the judge using medical and non-medical criteria. In all, the medical decision was upheld in 29 cases (38%) and over-ruled in 20 cases (26%). Thirteen cases (17%) were finally settled out of court, and 14 patients (18%) died before the end of the investigation. The qualitative analysis highlighted opposing moral values and principles put forward by family members and physicians.

Conclusion: The growing incidence and deeply intertwined elements of these conflicts call for more policy and research to resolve them before they go to court.

Background: Patients with Self-Reported Penicillin Allergy (SRPA) receive alternative antibiotics, which increase the length of stay and hospital costs, but the impact of SRPA on mortality in critically ill patients is not well described.

Methods: This was a single-center, retrospective analysis of routinely gathered clinical data for all intensive care unit (ICU) admissions over nine years. The primary outcome was 28-day mortality, which was analyzed using a time-to-event approach with multivariable models to adjust for confounding factors, including age, comorbidities, sex, and admission SOFA score (as a measure of organ dysfunction). Antibiotic prescriptions during the ICU stay were also interrogated and compared.

Results: Of 35319 admissions, 11.7% had SRPA. Compared with non-SRPA, patients with SRPA were more likely to be female (52.2% vs. 37.4%, p < 0.001) and had more comorbidities (p < 0.001) but had similar admission SOFA scores (median: 3.5 in both groups, p = 0.839). Patients with SRPA had significantly lower 28-day mortality (9.6% vs. 10.9%, p = 0.011). After multivariable adjustment for baseline characteristics, this effect persisted for unplanned (hazard ratio [HR]: 0.76, 95% CI: 0.68-0.86, p < 0.001), but not planned admissions (HR: 1.21, 95% CI: 0.92-1.58, p = 0.172). Whilst the duration of antibiotics in ICU was similar in the SRPA and non-SRPA groups (mean: 3.4 vs. 3.4 days, p = 0.663), the antibiotics used differed, with SRPA patients being significantly more likely to receive quinolones or other anti-Gram-positive antibiotics (p < 0.001).

Conclusion: SRPA was associated with a survival benefit that persisted after adjustment for confounders for unplanned ICU admissions. Patients with SRPA were more likely to receive antibiotics that are not active against anaerobic bacteria. critical care, penicillin allergy, antimicrobial allergy, mortality, antimicrobial stewardship, acute care.

Background: Global warming presents major public health challenges, with healthcare transportation significantly contributing to carbon dioxide equivalent emissions (eCO₂). While the greenhouse effects of anaesthetic gases are well-documented, the eCO₂ of pre-anaesthesia consultations remains underexplored. This study aims to evaluate and propose strategies to reduce the carbon impact of these consultations at a Tertiary University Hospital.

Methods: In a prospective, observational study over one month, data were collected from patients attending pre-anaesthesia consultations. ECO2 emissions from transportation and electricity were calculated. To reduce emissions, several modifications to the care pathway were investigated, including teleconsultation, remote consultation, grouping of consultations, carpooling, and the promotion of public transport. The effects of current and optimised care pathways were then compared.

Results: Data from 213 patients showed that 75% attended the hospital solely for pre-anaesthesia consultations, mostly by car (82%). The mean eCO₂ per consultation was 22.4 kgCO2 (95% CI: 14.6-30.2). Implementing optimisation strategies in 65% of cases could reduce emissions to 5.6 kgCO2 (95% CI: 0.2-10.9) per consultation, leading to a 74% reduction and an annual saving of 274 tonnes of eCO₂.

Discussion: Our study highlights the potential for significant reductions in the eCO₂ of pre-anaesthesia consultations. The adaptation of the care pathway would largely involve grouping consultations and developing teleconsultations. These potential savings in greenhouse gas emissions are in the same order of magnitude as not using desflurane in the operating theatre and could be the next step towards greener anaesthesia.

Background: Nurse retention is a major concern in healthcare settings, especially among intensive care units (ICU), in which nurses are highly specialized. The objective was to describe the nurse courses after their entrance into the ICU, their motivation for leaving the ICU, and to identify the independent factors that influenced the nurse resignation from their units.

Methods: In 3 different centers, every ICU nurse working between 2013 and 2023 was telephonically contacted and was asked to describe their career and, when appropriate, the reasons that influenced their resignation from their units; they rated on a Likert scale of 14 factors that influenced their decision.

Results: Among the 405 nurses who worked in these ICUs between 2013 and 2023, 265 (65.0%) were included in the study, and 93 (35.1%) were still working in their unit. The median time of professional experience of the nurses in their ICU was 5.8 [5.0-7.0] years, and at 10 years, 26.3%[20.4-33.9] of the nurses remained in their unit, 23.8% [17.3-32.8] left the ICU but were still in-hospital nurses, and 22.4% [15.8-31.7] underwent specialization. A minority of nurses resigned and changed their careers (9.5% [5.3-17.0]). The main factors influencing the nurse's resignation from their unit were belonging to Generation Y or Z (HR 1.89 [1.35;2.64]), experiencing symptoms of burnout (2.37 [1.63;3.46]), and pregnancy during the ICU (1.77 [1.41;2.23]). The COVID-19 period was inconsistently associated with nurse resignation depending on the center. The main motivations to leave the unit were organizational (variability of schedule, night shift), personal (willingness to change, personal event), and related to the ICU workload.

Conclusion: Nurse retention is an increasing concern, associated with the generational aspects and increased prevalence of burnout. Structural changes will have to be made to reduce the turnover.

Background: Indications for Veno-venous (VV) or veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) after trauma rely on poor evidence. The main aims were to describe the population of trauma patients requiring either VV or VA ECMO and report their clinical management and outcomes.

Methods: An observational multicentre retrospective study was conducted in 17 Level 1 trauma centres in France between January 2010 and December 2021. All patients admitted for major trauma were screened for inclusion, and those receiving either VV ECMO or VA ECMO were included. The primary outcome was in-hospital mortality.

Results: Among the 52,851 patients screened, 179 were included, with 143 supported by VV ECMO (median [Q1-Q3] age 32 years [24-48]; men 83.5%; injury severity score [ISS] 33 [25-43] and 76 (53.6%) with a traumatic brain injury [TBI]) and 36 supported by VA ECMO (median age 39 years [25-55]; men 88.9%; ISS 36 [25-56] and 23 (63.9%) with a TBI). In the VV ECMO group, three indications for ECMO implementation were chest injuries (n = 68, 47.6%), ventilator-associated pneumonia (VAP; n = 57, 39.9%), and extra-respiratory acute respiratory distress syndrome (ARDS; n = 57, 39.9%). In the VV ECMO group, 45.8% (n = 65) died in the hospital, with 33 (48.5%) deaths following cannulation for chest injuries, 22 (39.3%) following cannulation for VAP, and 10 (55.6%) following cannulation for extrapulmonary ARDS. In the VA ECMO group, 75.0% (n = 27) died during their hospital stay.

Conclusions: In-hospital mortality of trauma patients requiring ECMO for refractory ARDS varied according to indications. The best prognosis was observed in the subgroup of pneumonia-induced ARDS patients.