OBJECTIVES:Patients at risk of adverse effects related to positive fluid balance could benefit from fluid intake optimization. Less attention is paid to nonresuscitation fluids. We aim to evaluate the heterogeneity of fluid intake at the initial phase of resuscitation. DESIGN:Prospective multicenter cohort study. SETTING:Thirty ICUs across France and one in Spain. PATIENTS:Patients requiring vasopressors and/or invasive mechanical ventilation. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:All fluids administered by vascular or enteral lines were recorded over 24 hours following admission and were classified in four main groups according to their predefined indication: fluids having a well-documented homeostasis goal (resuscitation fluids, rehydration, blood products, and nutrition), drug carriers, maintenance fluids, and fluids for technical needs. Models of regression were constructed to determine fluid intake predicted by patient characteristics. Centers were classified according to tertiles of fluid intake. The cohort included 296 patients. The median total volume of fluids was 3546 mL (interquartile range, 2441-4955 mL), with fluids indisputably required for body fluid homeostasis representing 36% of this total. Saline, glucose-containing high chloride crystalloids, and balanced crystalloids represented 43%, 27%, and 16% of total volume, respectively. Whatever the class of fluids, center of inclusion was the strongest factor associated with volumes. Compared with the first tertile, the difference between the volume predicted by patient characteristics and the volume given was +1.2 ± 2.0 L in tertile 2 and +3.0 ± 2.8 L in tertile 3. CONCLUSIONS:Fluids indisputably required for body fluid homeostasis represent the minority of fluid intake during the 24 hours after ICU admission. Center effect is the strongest factor associated with the volume of fluids. Heterogeneity in practices suggests that optimal strategies for volume and goals of common fluids administration need to be developed.

La recherche documentaire peut servir plusieurs objectifs : répondre à une question clinique, préparer un protocole de recherche, un cours, une présentation orale ou même actualiser ses connaissances. Être à jour des dernières publications scientifiques demande une méthode afin d'identifier les articles pertinents. Nous proposons, au travers d’un article didactique, les bases pour organiser efficacement sa recherche documentaire. Ensuite, afin d’être tenu informé au fur et à mesure des nouvelles publications, les moyens permettant de conduire une veille scientifique sont abordés. Enfin, il convient d’organiser sa bibliographie et les publications à conserver. Des méthodes ainsi que des outils sont disponibles à cet effet. Nous vous en suggérons quelques-uns sans que la liste n'en soit exhaustive.

Background: Hand hygiene (HH) compliance among health-care workers is important for preventing transmission of infectious diseases. Aim: To describe health-care worker hand hygiene activity in ICU and non-ICU patients' rooms, using an automated monitoring system (AMS), before and after the onset of the COVID-19 pandemic.Methods: At the Intercommunal Hospital of Cre & PRIME;teil, near Paris, France, alcohol-based hand sanitizer (ABHS) consumption in the Department of Medicine (DM) and ICU was recorded using an AMS during four periods: before, during, and after the first wave of the COVID-19 pandemic, and during its second wave.Findings: From 1st February to 30th November 2020, in the DM, the mean number of doses per patient-day for each of the four periods was, respectively, 5.7 (& PLUSMN;0.3), 19.4 (& PLUSMN;1.3), 17.6 (& PLUSMN;0.7), and 7.9 (& PLUSMN;0.2, P 0.0001). In contrast, ICU ABHS consumption remained relatively constant. In the DM, during the pandemic waves, ABHS consumption was higher in rooms of COVID 19 patients than in other patients' rooms. Multivariate analysis showed ABHS consumption was associated with the period in the DM , with the number of HCWs in the ICU.Conclusion: An AMS allows real-time collection of ABHS consumption data that can be used to adapt training , prevention measures to specific hospital departments.(C) 2022 The Author(s). Published by Elsevier B.V. on behalf of Australasian College for Infection Prevention and Control. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

In France, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic has caused a major health crisis. Between March 1 and April 30, SARS-CoV-2 led to an excess daily mortality of 33% compared with average values for the years 2000 to 2019.1 As of 17th December 2020, a report published by the French National Public Health Agency indicates a cumulative number of 2 427 316 COVID-19 infected patients, with 59 619 deaths, 41 200 of these in hospital.2 The purpose of this critical commentary is to describe the COVID-19 crisis from the perspective of French intensive care unit (ICU) nurses and to discuss how the pandemic has finally facilitated appropriate recognition for French critical care nurses. This major crisis was managed nationally by the Ministry of Health, but every hospital had to locally manage the increased activity due to the admissions of COVID-19 patients with its own means. Decades of political decisions to decrease health costs has led to equipment and staff deficiencies for hospitals. To cope with these limited resources, health care professionals had to create new organizations and set up new collaborations. In the first days of the pandemic in France, health authorities expected that many patients would need intensive care, and an important gap between ICU capacity and demand was feared. Before the pandemic, French ICUs were already under pressure: with only 2.4 ICU beds for 10 000 citizens, half of that in Germany,3, 4 and physician and nurse numbers were already insufficient in several ICUs across the country. To face the epidemiological crisis forecast, the government ordered the creation of ICU beds wherever possible. Thus, between March and April 2020, the total number of ICU beds increased from 5000 to around 10 200.5, 6 The spread of the virus among French regions required the transfer of 202 critically ill patients to available critical care beds across the country.3 This massive ICU reorganization was only possible by adding to the existing critical care nursing staff with nurse anaesthetists, operating room nurses, and ward nurses freed up by the suspension of elective surgical and medical activities. Paediatric intensive care nurses were also involved because with the overwhelming number of adult patients admitted to ICUs, paediatric intensive care units became part of the front-line hospitalization strategy, especially in the most affected regions such as the East and the Parisian areas. Given the heterogeneity of the resources in these units, it was challenging to homogenize the skills, to ensure patient safety and to provide the best possible care. Experienced critical care nurses were therefore key players in educating the new nurses and supervising all critical nursing care. Because of this national hospital re-organization, a massive increase in activity and pre-existing shortages in supplies of medical devices and other resources, ICU teams showed great resourcefulness during the first wave of the pandemic. The shortage of drugs and mechanical ventilators was constant. ICU teams had to continually adapt to patient needs and balance demand with supply, and always look for alternative solutions. Preventing transmission to health professionals was also a priority during this period. The shortage of individual personal protective equipment items, like masks or gloves, led to a permanent search of solutions and was a stress-generating issue for whole teams. In addition, a further major source of stress was the strict restriction to relatives' visitation in most ICUs. It was considered unacceptable and morally distressing for health care providers to allow patients to face death in isolation from their relatives and these restricted visitation policies induced a psychological burden, especially for nurses.7 Since 2009, a 3-year program at a bachelor's level is required to become a registered nurse in France. On completion of this general education, no specific education program exists to prepare nurses to work in ICU. Additionally, current nurse shortages make recruitment less selective, and increasingly newly qualified nurses have their first job in an ICU. This basic nurse education produces versatile nurses but does not provide nurses with specialized skills in critical care. Despite the views of several associations of critical care nurses and the presence of nurses on the board and working groups of the societies of critical care, the French health authorities declined to recognize critical care nursing as a speciality or the need for any recognized post-graduate training to work in ICUs.8-10 Since 2019, a national curriculum has existed to train advanced practice nurses in the field of chronic diseases. This is the first university training programme at master's level that has extended nurses' range of practice. This first advanced practice nurse education in France represents an opportunity to enhance nurses' required skills, competencies, expertise, autonomy, and recognition. This expansion of ICU beds and the need for critical care nurses to staff them underscored the value of critical care nursing as a specialty. Indeed, every new nurse to ICU had to be trained to a minimal level to achieve basic competence in care of the ICU patient. Nonetheless, these nurses could still only provide basic care, for relatively stable patients without specific invasive support, such as extra corporeal membrane oxygenation (ECMO) or renal replacement therapy. It became very clear that experienced ICU nurses were essential and irreplaceable to ensure quality clinical care. In France, before the pandemic, approximatively 480 ICU beds nationally remained closed because of the shortage of nurses. A high turnover of nurses is observed in French ICUs,11 undoubtedly due to the work conditions (frequent night shifts and weekend work), the absence of specific recognition as a critical care nurse (especially compared with numerous European countries), poor pay (remuneration below the French average wage4), and the absence of a professional critical care nurse educational program. Currently, French nurses develop critical care specific skills through on-the-job training. This approach is far from that recommended by the World Federation of Critical Care Nurses, back in 2005, which stressed that critically ill patients have very special needs and must be cared for by nurses with specialist skills, knowledge, and attitudes12 In France, the few courses for critical care nurses that exist are locally delivered and heterogeneous in their content and assessment. Since the beginning of the COVID-19 crisis, French critical care medical societies supported the positions and the claims of the critical care nurses. More than ever, they underlined the numerous skills ICU nurses possess and how unrecognized they are. In addition to highlighting the wide range of skills these nurses have, they stressed how these skills (or lack of them) may affect patient outcomes. During the COVID-19 pandemic, ICU nurses demonstrated real clinical and organizational leadership. Their knowledge and experience were essential for the quality of nursing care in the ICUs.13 They created educational tools about the nursing care of critically ill patients for their inexperienced colleagues, and also spread COVID-19 specific recommendations. Supported by a national network, they shared these resources across France using e-learning platforms and dedicated web meetings. Due to the overriding role of ICUs during this COVID-19 crisis, and the support from the population to the health service, ICU nurses were reminded about the importance of their mission. Possibly for the first time in France, they felt like they were not only nurses working in ICUs, but “critical care nurses.” It was this particular feeling that has led them to unite. Prompted by a group of nurses already involved in French critical care associations and scientific societies, the French federation of Critical Care Nurses (FfCCN) was founded. Its main objectives were to gather all French nurses working in ICUs and to have them recognized and valued as “critical care nurses,” a professional identity distinct from that of other nurses. This young federation, including both adult and paediatric ICU nurses, has been well received by the critical care professionals and the medical community who promoted and supported it since the beginning of the COVID-19 outbreak. The FfCCN is now working to develop a specific national educational program, similar to those that exist in many other countries. In addition, to improving the quality of nursing care and patient outcomes, this new training is also a powerful way to minimize the turnover of nurses in the ICUs11 by valuing them, even financially, and giving them the status they deserve. Nurses' specialization appears to be a natural process with the increasing complexity of patients' needs, nurses' knowledge, and techniques.14 Nurses working in ICUs require technical professional and human skills and there is substantial consensus about the importance of optimum staffing by nurses, with a significant proportion of them holding critical care post-registration qualifications.15 Therefore, many countries have a national curriculum to train critical care nurses16 and a concrete policy to promote nurses' specialization in the ICU.17, 18 It is now timely that the question of formally recognising this specialization for critical care nurses in France is addressed, whether for the care of adults, children or premature new-borns, especially now that nursing science is being taught at university. This is an additional opportunity to consider a recognized specialised training program, at master's level in critical care nursing in France.

The COVD-19 wave of spring 2020 had a major impact on French intensive care departments. The intense activity, the support of reinforcements in the acquisition of the necessary skills and their capacity to adapt made intensive care nurses key players in this crisis. Grouped together within the French National Federation of Intensive Care Nurses, they are campaigning to have the specificity of their practice to be recognised and for the creation of certified training in order to meet public healthcare needs not currently fulfilled.

The COVD-19 wave of spring 2020 had a major impact on French intensive care departments. The intense activity, the support of reinforcements in the acquisition of the necessary skills and their capacity to adapt made intensive care nurses key players in this crisis. Grouped together within the French National Federation of Intensive Care Nurses, they are campaigning to have the specificity of their practice to be recognised and for the creation of certified training in order to meet public healthcare needs not currently fulfilled.

The COVD-19 wave of spring 2020 had a major impact on French intensive care departments. The intense activity, the support of reinforcements in the acquisition of the necessary skills and their capacity to adapt made intensive care nurses key players in this crisis. Grouped together within the French National Federation of Intensive Care Nurses, they are campaigning to have the specificity of their practice to be recognised and for the creation of certified training in order to meet public healthcare needs not currently fulfilled.

The COVD-19 wave of spring 2020 had a major impact on French intensive care departments. The intense activity, the support of reinforcements in the acquisition of the necessary skills and their capacity to adapt made intensive care nurses key players in this crisis. Grouped together within the French National Federation of Intensive Care Nurses, they are campaigning to have the specificity of their practice to be recognised and for the creation of certified training in order to meet public healthcare needs not currently fulfilled.

Rationale: The weaning process concerns all patients receiving mechanical ventilation. A previous classification into simple, prolonged, and difficult weaning ignored weaning failure and presupposed the use of spontaneous breathing trials.Objectives: To describe the weaning process, defined as starting with any attempt at separation from mechanical ventilation and its prognosis, according to a new operational classification working for all patients under ventilation.Methods: This was a multinational prospective multicenter observational study over 3 months of all patients receiving mechanical ventilation in 36 intensive care units, with daily collection of ventilation and weaning modalities. Pragmatic definitions of separation attempt and weaning success allowed us to allocate patients in four groups.Measurements and Main Results: A total of 2,729 patients were enrolled. Although half of them could not be classified using the previous definition, 99% entered the groups on the basis of our new definition as follows: 24% never started a weaning process, 57% had a weaning process of less than 24 hours (group 1), 10% had a difficult weaning of more than 1 day and less than 1 week (group 2), and 9% had a prolonged weaning duration of 1 week or more (group 3). Duration of ventilation, intensive care unit stay, and mortality (6, 17, and 29% for the three groups, respectively) all significantly increased from one group to the next. The unadjusted risk of dying was 19% after the first separation attempt and increased to 37% after 10 days.Conclusions: A new classification allows us to categorize all weaning situations. Every additional day without a weaning success after the first separation attempt increases the risk of dying.

L’EER sert à « remplacer » la fonction rénale lorsque cette dernière ne permet plus le maintien de l’homéostasie. L’objectif est de retirer les substances toxiques accumulées dans le sang (potassium, urée, créatinine, phosphore…), d’apporter du bicarbonate pour corriger l’acidose et de contrôler la balance hydrosodée. L’EER est une urgence lorsqu’une complication de l’insuffisance rénale (hyperkaliémie, hyponatrémie, acidose, œdème pulmonaire) met en jeu le pronostic vital.

RATIONALE:Many patients with severe acute respiratory distress syndrome (ARDS) caused by influenza A(H1N1) infection receive extracorporeal membrane oxygenation (ECMO) as a rescue therapy.OBJECTIVES:To analyze factors associated with death in ECMO-treated patients and the influence of ECMO on intensive care unit (ICU) mortality.METHODS:Data from patients admitted for H1N1-associated ARDS to French ICUs were prospectively collected from 2009 to 2011 through the national REVA registry. We analyzed factors associated with in-ICU death in ECMO recipients, and the potential benefit of ECMO using a propensity score-matched (1:1) cohort analysis.MEASUREMENTS AND MAIN RESULTS:A total of 123 patients received ECMO. By multivariate analysis, increasing values of age, lactate, and plateau pressure under ECMO were associated with death. Of 103 patients receiving ECMO during the first week of mechanical ventilation, 52 could be matched to non-ECMO patients of comparable severity, using a one-to-one matching and using control subjects only once. Mortality did not differ between the two matched cohorts (odds ratio, 1.48; 95% confidence interval, 0.68-3.23; P = 0.32). Interestingly, the 51 ECMO patients who could not be matched were younger, had lower Pa(o(2))/Fi(o(2)) ratio, had higher plateau pressure, but also had a lower ICU mortality rate than the 52 matched ECMO patients (22% vs. 50%; P < 0.01).CONCLUSIONS:Under ECMO, an ultraprotective ventilation strategy minimizing plateau pressure may be required to improve outcome. When patients with severe influenza A(H1N1)-related ARDS treated with ECMO were compared with conventionally treated patients, no difference in mortality rates existed. The unmatched, severely hypoxemic, and younger ECMO-treated patients had, however, a lower mortality.