Les conditions particulières d’exercice de la réanimation peuvent entrainer, parmi les professionnels, une altération effective ou ressentie de la Qualité de Vie et des conditions au Travail (QVcT) se traduisant par une perte de sens du soin et des conflits de valeurs. Il apparait donc indispensable de développer une culture de service et un climat éthique au sein des services de réanimation autour d’un corpus de valeurs, identifiées par les professionnels comme un guide ou une boussole garant de la qualité et de la sécurité des soins. Cette démarche nécessite de s’appuyer sur une dynamique participative anticipée et interdisciplinaire, impliquant patients, soignants, proches, médecins référents et consultants afin de faciliter les prises de décisions, l’autonomisation des professionnels, les pratiques et les organisations, avec le respect mutuel des prises de paroles et des positionnements des acteurs. Ainsi, il s’agira de limiter l’installation d’un silence éthique au profit d’un relativisme éthique en améliorant la communication et la dispensation d’informations claires, adaptées et compréhensibles pour garantir la cohésion et l’engagement des équipes au sein des services de réanimation. Ainsi, les valeurs éthiques du soin seront reconnues tout au long du parcours du patient en réanimation.

Postintensive care syndrome (PICS) encompasses physical, psychological, and cognitive sequelae following an intensive care unit (ICU) stay, with repercussions also extending to patients’ families (PICS-F). Beyond health-related outcomes, ICU survivors frequently face social and economic challenges, including reduced income, unemployment, social isolation, and increased dependence on welfare. Socioeconomic status (SES), defined by access to material, human, and social resources, is a major determinant of health inequities and influences both the risk and severity of PICS. Evidence suggests that low SES is associated with poorer quality of life, increased need for long-term care, and higher mortality after ICU discharge. Recent studies show that educational level and employment status significantly impact long-term recovery, underlining the interaction between social vulnerability and PICS. The ongoing SOPICS trial will further explore these associations using the EPICES score to identify high-risk patients. Integrating SES into PICS management is essential, with social workers playing a central role in coordinating discharge planning, welfare access, and support services. Future research should assess the impact of tailored social interventions on PICS outcomes, aiming to mitigate inequities and improve reintegration after critical illness.

Background/Objectives: Adults under legal protection experience management delays and prolonged hospitalization. This study investigated whether ICU outcomes differ between patients with versus without legal protection. Methods: This retrospective, single-center study evaluated patients admitted to a French ICU (July 2015-July 2023). Protected patients were compared to autonomous controls matched 1:3 by age and admission year. Results: Of the 1051 patients included, 266 (25.3%) were under legal protection. The protected group had a higher proportion of women (43.2% vs. 35.7%, p = 0.025), received renal replacement therapy less frequently (8.6% vs. 15.4%, p = 0.007), and required non-invasive ventilation more frequently (25.2% vs. 17.2%, p = 0.004) than controls. Three-month mortality was 38.7% in controls versus 33.1% in protected patients, showing no significant difference after multivariable adjustment for 6 prespecified clinical variables (aOR 0.816, 95% CI 0.564 to 1.180). In the adjusted model, higher SAPS II scores and vasopressor use were significantly associated with increased 3-month mortality, whereas non-invasive ventilation and non-respiratory admission indications (sepsis, renal failure, trauma) were associated with decreased mortality. Conclusions: No significant association was observed between the presence of a legal protection measure prior to ICU admission and 3-month patient mortality. However, these results must be interpreted with caution due to a potential lack of statistical power. Additionally, legally protected patients were observed to receive renal replacement therapy less frequently, whereas non-invasive ventilation was utilized more frequently. Within this context, further research is required to evaluate the impact of legal protection status on the formal collegial deliberations that lead to decisions regarding the limitation of life-sustaining treatments.

L’évolution du métier de réanimateur doit prendre en compte le bien-être physique et psychologique ainsi que les besoins sociaux des patients et de leurs proches grâce à une humanisation du soin : « le care », tout en considérant les besoins de celles et ceux qui soignent. Cette évolution doit permettre une transition entre le fait de « faire de la réanimation » aux aspects techniques indispensables mais potentiellement « deshumanisants », et le fait de « devenir réanimateur », état d’esprit qui nécessite formation, compagnonnage (acquisition d’un savoir expérientiel) et prise en compte d’une notion de plus en plus prégnante qui est celle de « service rendu » au patient. Ainsi, évoluer de la réanimation proprement dite à « la non-réanimation », à la « dé-réanimation » et au « suivi post-réanimation » constitue la base de la réflexion autour du métier de réanimateur. Cette démarche contribuera à prévenir, grâce aux réflexions partagées et multidisciplinaires, des soins jugés inutiles, une qualité empêchée et une perte de sens au travail, source de souffrance psychique et de perte d’attractivité et de diminution de la fidélisation aux métiers des soins critiques.

Introduction Postextubation swallowing disorders (SD) are common in the intensive care unit (ICU) and are associated with severe complications, including aspiration pneumonia, a three-fold increase in reintubation risk and higher mortality. While fibreoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy are gold standards for diagnosis, they are often impractical or impossible to perform on intubated patients. The use of ultrasound offers a non-invasive, bedside alternative to evaluate the musculoskeletal structures involved in swallowing. The Echographie Identifier les troubles de Déglutition Acquis en Réanimation (EIDAR) study aims to evaluate the diagnostic performance of pre-extubation ultrasound in identifying patients at risk of SD following mechanical ventilation.Methods and analysis This prospective, monocentric diagnostic study conducted at the Dijon University Hospital ICU will include 100 adult patients ventilated for ≥48 hours. The primary outcome is the presence of SD, defined as a Penetration-Aspiration Scale score >2 during a FEES procedure performed 3 to 24 hours postextubation and independently assessed by an otolaryngologist blinded to index test results. Pre-extubation cervical ultrasound (Index Test) will be performed within 3 hours prior to extubation and measure hyoid bone ascension (primary variable of interest), geniohyoid muscle surface area and digastric muscle cross-sectional area. The diagnostic performance of cervical ultrasonographic parameters will be assessed using their discriminative capacity via a receiver operating characteristic curve. The feasibility of the ultrasound procedure in a critical care setting will also be assessed.Ethics and dissemination The study received a favourable opinion from the independent ethics committee CPP Ouest III and is registered with the French health authority ANSM (national agency on safety in medicine and health products). It is conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Participants or their proxies provide free and informed oral consent. Results will be submitted for publication in peer-reviewed medical journals and presented at international conferences.Trial registration numbers RCB 2023-A00461-44 and NCT05922085

Background: Reducing critically ill patients’ exposure to antibiotics is mandatory. In randomized controlled trials, procalcitonin (PCT)-guided algorithms (i.e., antibiotic therapy [ABT] should be stopped whenever PCT is less than 0.5 µg/L or is below 80% of the peak value) reduced the duration of (ABT) more than compliance with the current guidelines. However, the interest of such stopping rules in daily practice remains debated. Thus, we carried out a real-life study addressing this issue. Results: During the study period, 112 patients with sepsis upon intensive care unit admittance were included. The median age was 66 years (56–79). Half of the patients presented with acute respiratory failure. Pneumonia was diagnosed in 78% of them, and 41% met septic shock criteria. The initial ABT was empirical in most cases, and appropriateness rate to the isolated bacteria reached 71%. A median number of four PCT measurements was achieved in both groups. The compliance rate with the PCT algorithm was 54%. The median duration of ABT was 5 (4–7) days if the PCT algorithm was followed, as compared to 7 (5–10) days otherwise (p < 0.001). This ABT stopping rule allowed a 2-day reduction in the treatment duration as compared with those recommended by the guidelines (p < 0.001). The only independent factor associated with shorter treatment duration was compliance with the PCT algorithm (OR = 0.74, 95% CI [0.62; 0.88]; p < 0.001). Regarding safety, no difference in outcome was found between the two groups. Conclusions: Complying with one PCT-based stopping rule is associated with a significant reduction in the duration of ABT in septic critically ill patients, without apparent impact on patient outcomes.

Whether the use of inhaled or intravenous sedation affects outcomes differentially in mechanically ventilated adults with acute respiratory distress syndrome (ARDS) is unknown. To determine the efficacy and safety of inhaled sevoflurane compared with intravenous propofol for sedation in patients with ARDS. Phase 3 randomized, open-label, assessor-blinded clinical trial conducted from May 2020 to October 2023 with 90-day follow-up. Adults with early moderate to severe ARDS (defined by a ratio of Pao2 to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure of ≥8 cm H2O) were enrolled in 37 French intensive care units. Patients were randomized to a strategy of inhaled sedation with sevoflurane (intervention group) or to a strategy of intravenous sedation with propofol (control group) for up to 7 days. The primary end point was the number of ventilator-free days at 28 days; the key secondary end point was 90-day survival. Of 687 patients enrolled (mean [SD] age, 65 [12] years; 30% female), 346 were randomized to sevoflurane and 341 to propofol. The median total duration of sedation was 7 days (IQR, 4 to 7) in both groups. The number of ventilator-free days through day 28 was 0.0 days (IQR, 0.0 to 11.9) in the sevoflurane group and 0.0 days (IQR, 0.0 to 18.7) in the propofol group (median difference, −2.1 [95% CI, −3.6 to −0.7]; standardized hazard ratio, 0.76 [95% CI, 0.50 to 0.97]). The 90-day survival rates were 47.1% and 55.7% in the sevoflurane and propofol groups, respectively (hazard ratio, 1.31 [95% CI, 1.05 to 1.62]). Among 4 secondary outcomes, sevoflurane was associated with higher 7-day mortality (19.4% vs 13.5%, respectively; relative risk, 1.44 [95% CI, 1.02 to 2.03]) and fewer intensive care unit–free days through day 28 (median, 0.0 [IQR, 0.0 to 6.0] vs 0.0 [IQR, 0.0 to 15.0]; median difference, –2.5 [95% CI, –3.7 to –1.4]) compared with propofol. Among patients with moderate to severe ARDS, inhaled sedation with sevoflurane resulted in fewer ventilator-free days at day 28 and lower 90-day survival than sedation with propofol. ClinicalTrials.gov Identifier: NCT04235608

BACKGROUND:In patients with shock, whether noninvasive blood-pressure monitoring is an effective alternative to the recommended use of an arterial catheter is uncertain. METHODS:In this multicenter, open-label, noninferiority trial, we randomly assigned patients who had shock and had been admitted to an intensive care unit within the past 24 hours to receive early insertion (<4 hours after randomization) of an arterial catheter (invasive strategy) or to be monitored with an automated brachial cuff (noninvasive strategy). Insertion of an arterial catheter was allowed later in patients assigned to the noninvasive-strategy group who met prespecified safety criteria. The primary outcome was death from any cause at day 28 (noninferiority margin, 5 percentage points). Adverse events of special interest related to the blood-pressure-monitoring device that was used were recorded, as was patient-reported pain or discomfort related to the ongoing presence of the device. RESULTS:A total of 1010 patients underwent randomization; 504 patients assigned to the noninvasive-strategy group and 502 assigned to the invasive-strategy group were included in the analyses. A total of 74 patients (14.7%) in the noninvasive-strategy group and 493 (98.2%) in the invasive-strategy group underwent insertion of an arterial catheter. Death within 28 days occurred in 173 patients (34.3%) in the noninvasive-strategy group and 185 (36.9%) in the invasive-strategy group (adjusted risk difference, -3.2 percentage points; 95% confidence interval, -8.9 to 2.5; P = 0.006 for noninferiority). Results of per-protocol analyses were similar in the two groups. A total of 66 patients (13.1%) in the noninvasive-strategy group and 45 (9.0%) in the invasive-strategy group had at least 1 day of pain or discomfort related to the ongoing presence of the blood-pressure-monitoring device. Hematoma or hemorrhage related to the arterial catheter occurred in 5 patients (1.0%) in the noninvasive-strategy group and 41 patients (8.2%) in the invasive-strategy group. CONCLUSIONS:Among patients with shock, results for death from any cause at day 28 indicated that management without early arterial catheter insertion was noninferior to early catheter insertion. (Funded by the French Ministry of Health; ClinicalTrials.gov number, NCT03680963.).

Purpose The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI. Methods We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < - 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < - 3), incomplete awakening (RASS [- 3; - 2]), awakening (RASS [- 1; + 1] two consecutive days), and agitation (RASS > + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization. Results A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17-0.78]; p = 0.010). Time spent awake was 10.11 days [8.11-12.15] and 7.63 days [5.57-9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results. Conclusion In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.

Les directives anticipées (DA) qui faisaient partie du dispositif législatif français depuis le 22 avril 2005 s’imposent au médecin depuis la loi du 02 février 2016. Elles sont désormais l’expression de la volonté du patient et non plus celle de son souhait. Il est raisonnable d’imaginer dès lors que les DA puissent être réfléchies et rédigées à tout moment du parcours de soin du patient, mais également qu’elles puissent aborder toutes les potentialités évolutives de la maladie et, en particulier, l’éventualité d’une admission en réanimation. Dans cet article, les auteurs discutent de la place du médecin intensiviste comme interlocuteur priviligié dans le parcours de soin du patient et de son rôle potentiel dans l’élaboration anticipée d’objectifs thérapeutiques pouvant inclure la rédaction de DA. Il est abordé la question des outils et les stratégies utiles pour répondre à ces objectifs, y compris la question de la pertinence d’une admission en réanimation. Des pistes de réflexion sont également discutées, comme l’amélioration de la communication et l’anticipation des discussions qui pourraient être tracées dans l’espace internet développé par l’Assurance Maladie : « Mon Espace Santé », rubrique « Entourage et Volontés ».

INTRODUCTION:Non-beneficial stays in the intensive care unit (ICU) may have repercussions for patients and their families, but can also cause suffering among the nursing staff. We aimed explore the perceptions of nursing staff in the ICU about patient stays that are deemed to be "non-beneficial" for the patient, to identify areas amenable to intervention, with a view to improving how the nursing staff perceive the patient pathway before, during and after intensive care.METHODS:Multicentre, qualitative study using individual, semi-structured interviews. All qualified nurses and nurses' aides who were full-time employees in the ICU of three participating centres were invited to participate. Interviews were recorded, transcribed and analyzed using textual content analysis.RESULTS:A total of 21 interviews were performed from February 2020 to October 2021, at which point saturation was reached in the data. Average age of participants was 38.5±7.5 years, and they had an average of 10.7±7.4 years of experience working in the ICU. Four major themes emerged from the interviews, namely: (1) the work is oriented towards life-threatening emergencies, technical procedures and burdensome care; (2) a range of specific criteria and circumstances influence the decisions to admit patients to ICU; (3) there are significant organisational, physical and psychological repercussions associated with a non-beneficial stay in the ICU; (4) respondents made some proposals for improvements to the patient care pathway.CONCLUSION:Nursing staff have a similar perception to physicians regarding admission decisions and non-beneficial ICU stays. The possibility of future ICU admission needs to be anticipated, discussed systematically with patients and integrated into healthcare goals that are consistent with the patient's wishes and preferences, in multi-professional collaboration including nursing and medical staff.

The emergence of the new SARS-CoV-2 in December 2019 caused a worldwide pandemic of the resultant disease, COVID-19. There was a massive surge in admissions to intensive care units (ICU), notably of patients with hypoxaemic acute respiratory failure. In these patients, optimal oxygen therapy was crucial. In this article, we discuss tracheal intubation to provide mechanical ventilation in patients with hypoxaemic acute respiratory failure due to SARS-CoV-2. We first describe the pathophysiology of respiratory anomalies leading to acute respiratory distress syndrome (ARDS) due to infection with SARS-CoV-2, and then briefly review management, focusing particularly on the ventilation strategy. Overall, the ventilatory management of ARDS due to SARS-CoV-2 infection is largely the same as that applied in ARDS from other causes, and lung-protective ventilation is recommended. The difference lies in the initial clinical presentation, with profound hypoxaemia often observed concomitantly with near-normal pulmonary compliance.

Purpose: We investigated experiences of families who provide consent for research on behalf of a loved-one hospitalized in intensive care (ICU). Methods: Multicentre, qualitative, descriptive study using semi-directive interviews in 3 ICUs. Eligible relatives were aged >18 years, and had provided informed consent for a clinical trial on behalf of a patient hospitalized in ICU. Interviews were conducted from 06/2018 to 06/2019 by a qualified sociologist, recorded and transcribed. Results: Fifteen relatives were interviewed; average age 50.3 +/- 15 years. All emphasized their interest in clinical research, seeing it as a duty. Involving their loved-one in research allowed them to find meaning in the events. Participants underlined that trust in caregivers and communication are determinant. The strict regulation of research was perceived as a guarantee of safety. Participants felt they lacked the intellectual capacity and knowledge to question explanations. The greatest fear was not that they might incur a risk for the patient, but rather, that they might deprive the patient of a chance at a cure. Conclusion: Acceptance of research opportunities by relatives on behalf of decisionally-incapacitated patients is underpinned by trust in the physicians and the legislative framework. Communication and the quality of information provided by the caregivers are key. (c) 2020 Elsevier Inc. All rights reserved.

BACKGROUND:We conducted a systematic review of studies investigating lock solutions for use in non-tunneled hemodialysis catheters.METHODS:We searched PubMed and Cochrane databases from inception to June 11, 2021. Study inclusion criteria were: randomized trial or observational study, adults (>18 years), with acute kidney injury (AKI); and temporary non-tunneled catheters. We recorded bleeding events, catheter dysfunction and complications.RESULTS:Of 649 studies identified, 6 were included (4 randomized, 1 non-randomized trial, 1 retrospective cohort study; sample sizes 78-1496 patients). Citrate was compared to heparin in 4 studies, to saline in 1, and ethanol versus saline in 1. Event-free survival of non-tunneled catheters did not differ between groups. Catheter-related infections and adverse events were less frequent with citrate locks, but reached statistical significance in only two studies.CONCLUSION:Existing data are too heterogeneous to enable recommending one type of catheter lock over any other for non-tunneled hemodialysis catheters.

Background::We investigated the criteria that hospitalized patients in intensive care units (ICUs) deem important when designating relatives who are best qualified to interact with the caregiving staff.Methods::We conducted an exploratory, observational, prospective, multicenter study between March 1, 2018, and October 31, 2018, within two ICUs. A 12-item questionnaire was distributed to patients in the ICUs by the investigating physicians. Patients were considered eligible if they had a good understanding of the French language and if they had not officially designated surrogates before ICU admission.Results::Seventy-one patients whose average age was 63.9± 17.3 years, of whom 21 (29.5%) were females, completed the questionnaire. The average Charlson comorbidity score was 2.5 ± 2.4, and the average Simplified Acute Physiology Score (SAPS II) was 39.8 ± 16.5. The main etiology was respiratory infection (40.8%), followed by sepsis (23.9%). The most important criteria identified by patients when selecting reference persons were a good knowledge of the patient’s wishes and values, an emotional attachment to the patient, and being a family member.Conclusion::Our findings reveal that ICU patients considered the following criteria to be critical when designating reference persons: knowledge of their wishes and the existence of emotional and family attachments.

Background. Given the rapidly evolving pandemic of COVID-19 in 2020, authorities focused on the repurposing of available drugs to develop timely and cost-effective therapeutic strategies. Evidence suggested the potential utility of remdesivir in the framework of an early access program. REMDECO-19 is a multicenter national cohort study assessing the ability of remdesivir to improve the outcome of patients hospitalized with COVID-19. Methods. We conducted a retrospective real-life study that included all patients from the early access program of remdesivir in France. The primary endpoint was the clinical course evolution of critically ill and hospitalized COVID-19 patients treated with remdesivir. Secondary endpoints were the SOFA score evolution within 29 days following the admission and mortality at 29 and 90 days. Results. Eighty-five patients were enrolled in 22 sites from January to April 2020. The median WHO and SOFA scores were respectively reduced by two and six points between days 1 and 29. Improvement in the WHO-CPS and the SOFA score were observed in 83.5% and 79.3% of patients, respectively, from day 10. However, there was no effect of remdesivir on the 90-day survival based on the control cohort for hospitalized COVID-19 patients with invasive ventilation. Conclusions. SOFA score appeared to be an attractive approach to assess remdesivir efficacy and stratify its utilization or not in critically ill patients with COVID-19. This study brings a new clinical benchmark for therapeutic decision making and supports the use of remdesivir for some hospitalized COVID-19 patients.

Introduction We investigated the reflections and perceptions of non-ICU physicians about anticipating the need for ICU admission in case of acute decompensation in patients with chronic disease. Methods We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient’s healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient’s healthcare goals? Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached. Results In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such situations. The timing of discussions about potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient’s healthcare goals or wishes. Conclusion This study describes the perceptions that physicians treating patients with chronic disease have of intensive care, notably that it is a distinct and technical specialty that presents challenging medical and ethical situations. Our study also opens perspectives for actions that could promote a pluridisciplinary approach to anticipating acute decompensation and ICU requirements in patients with chronic disease.

BackgroundThe Solidarity trial among COVID-19 inpatients has previously reported interim mortality analyses for four repurposed antiviral drugs. Lopinavir, hydroxychloroquine, and interferon (IFN)-β1a were discontinued for futility but randomisation to remdesivir continued. Here, we report the final results of Solidarity and meta-analyses of mortality in all relevant trials to date.MethodsSolidarity enrolled consenting adults (aged ≥18 years) recently hospitalised with, in the view of their doctor, definite COVID-19 and no contraindication to any of the study drugs, regardless of any other patient characteristics. Participants were randomly allocated, in equal proportions between the locally available options, to receive whichever of the four study drugs (lopinavir, hydroxychloroquine, IFN-β1a, or remdesivir) were locally available at that time or no study drug (controls). All patients also received the local standard of care. No placebos were given. The protocol-specified primary endpoint was in-hospital mortality, subdivided by disease severity. Secondary endpoints were progression to ventilation if not already ventilated, and time-to-discharge from hospital. Final log-rank and Kaplan-Meier analyses are presented for remdesivir, and are appended for all four study drugs. Meta-analyses give weighted averages of the mortality findings in this and all other randomised trials of these drugs among hospital inpatients. Solidarity is registered with ISRCTN, ISRCTN83971151, and ClinicalTrials.gov, NCT04315948.FindingsBetween March 22, 2020, and Jan 29, 2021, 14 304 potentially eligible patients were recruited from 454 hospitals in 35 countries in all six WHO regions. After the exclusion of 83 (0·6%) patients with a refuted COVID-19 diagnosis or encrypted consent not entered into the database, Solidarity enrolled 14 221 patients, including 8275 randomly allocated (1:1) either to remdesivir (ten daily infusions, unless discharged earlier) or to its control (allocated no study drug although remdesivir was locally available). Compliance was high in both groups. Overall, 602 (14·5%) of 4146 patients assigned to remdesivir died versus 643 (15·6%) of 4129 assigned to control (mortality rate ratio [RR] 0·91 [95% CI 0·82–1·02], p=0·12). Of those already ventilated, 151 (42·1%) of 359 assigned to remdesivir died versus 134 (38·6%) of 347 assigned to control (RR 1·13 [0·89–1·42], p=0·32). Of those not ventilated but on oxygen, 14·6% assigned to remdesivir died versus 16·3% assigned to control (RR 0·87 [0·76–0·99], p=0·03). Of 1730 not on oxygen initially, 2·9% assigned to remdesivir died versus 3·8% assigned to control (RR 0·76 [0·46–1·28], p=0·30). Combining all those not ventilated initially, 11·9% assigned to remdesivir died versus 13·5% assigned to control (RR 0·86 [0·76–0·98], p=0·02) and 14·1% versus 15·7% progressed to ventilation (RR 0·88 [0·77–1·00], p=0·04). The non-prespecified composite outcome of death or progression to ventilation occurred in 19·6% assigned to remdesivir versus 22·5% assigned to control (RR 0·84 [0·75–0·93], p=0·001). Allocation to daily remdesivir infusions (vs open-label control) delayed discharge by about 1 day during the 10-day treatment period. A meta-analysis of mortality in all randomised trials of remdesivir versus no remdesivir yielded similar findings.InterpretationRemdesivir has no significant effect on patients with COVID-19 who are already being ventilated. Among other hospitalised patients, it has a small effect against death or progression to ventilation (or both).FundingWHO.

Biofilm (BF) growth is believed to play a major role in the development of ventilator-associated pneumonia (VAP) in the intensive care unit. Despite concerted efforts to understand the potential implication of endotracheal tube (ETT)-BF dispersal, clinically relevant data are lacking to better characterize the impact of its mesostructure and microbiological singularity on the occurrence of VAP. We conducted a multicenter, retrospective observational study during the third wave of the COVID-19 pandemic, between March and May 2021. In total, 64 ETTs collected from 61 patients were included in the present BIOPAVIR study. Confocal microscopy acquisitions revealed two main morphological aspects of ETT-deposited BF: (1) a thin, continuous ribbon-shaped aspect, less likely monobacterial and predominantly associated with Enterobacter spp., Streptococcus pneumoniae or Viridans streptococci, and (2) a thicker, discontinuous, mushroom-shaped appearance, more likely characterized by the association of bacterial and fungal species in respiratory samples. The microbiological characterization of ETT-deposited BF found higher acquired resistance in more than 80% of analyzed BF phenotypes, compared to other colonization sites from the patient’s environment. These findings reveal BF as a singular microbiological compartment, and are of added clinical value, with a view to future ETT-deposited BF-based antimicrobial stewardship in critically ill patients. Trial registration NCT04926493. Retrospectively registered 15 June 2021.

Purpose Deciding not to re-admit a patient to the intensive care unit (ICU) poses an ethical dilemma for ICU physicians. We aimed to describe and understand the attitudes and perceptions of ICU physicians regarding non-readmission of patients to the ICU. Materials and methods Multicenter, qualitative study using semi-directed interviews between January and May 2019. All medical staff working full-time in the ICU of five participating centres (two academic and three general, non-academic hospitals) were invited to participate. Participants were asked to describe how they experienced non-readmission decisions in the ICU, and to expand on the manner in which the decision was made, but also on the traceability and timing of the decision. Interviews were recorded, transcribed and analyzed using textual content analysis. Results In total, 22 physicians participated. Interviews lasted on average 26±7 minutes. There were 14 men and 8 women, average age was 35±9 years, and average length of ICU experience was 7±5 years. The majority of respondents said that they regretted that the question of non-readmission was not addressed before the initial ICU admission. They acknowledged that the ICU stay did lead to more thorough contemplation of the overall goals of care. Multidisciplinary team meetings could help to anticipate the question of readmission within the patient’s care pathway. Participants reported that there is a culture of collegial decision-making in the ICU, although the involvement of patients, families and other healthcare professionals in this process is not systematic. The timing and traceability of non-readmission decisions are heterogeneous. Conclusions Non-readmission decisions are a major issue that raises ethical questions surrounding the fact that there is no discussion of the patient’s goals of care in advance. Better anticipation, and better communication with the patients, families and other healthcare providers are suggested as areas that could be targeted for improvement.