Introduction In case of COVID-19 related scarcity of critical care resources, an early French triage algorithm categorized critically ill patients by probability of survival based on medical history and severity, with four priority levels for initiation or continuation of critical care: P1 –high priority, P2 –intermediate priority, P3 –not needed, P4 –not appropriate. This retrospective multi-center study aimed to assess its classification performance and its ability to help saving lives under capacity saturation. Methods ICU patients admitted for severe COVID-19 without triage in spring 2020 were retrospectively included from three hospitals. Demographic data, medical history and severity items were collected. Priority levels were retrospectively allocated at ICU admission and on ICU day 7–10. Mortality rate, cumulative incidence of death and of alive ICU discharge, length of ICU stay and of mechanical ventilation were compared between priority levels. Calculated mortality and survival were compared between full simulated triage and no triage. Results 225 patients were included, aged 63.1±11.9 years. Median SAPS2 was 40 (IQR 29–49). At the end of follow-up, 61 (27%) had died, 26 were still in ICU, and 138 had been discharged. Following retrospective initial priority allocation, mortality rate was 53% among P4 patients (95CI 34–72%) versus 23% among all P1 to P3 patients (95CI 17–30%, chi-squared p = 5.2e-4). The cumulative incidence of death consistently increased in the order P3, P1, P2 and P4 both at admission (Gray’s test p = 3.1e-5) and at reassessment (p = 8e-5), and conversely for that of alive ICU discharge. Reassessment strengthened consistency. Simulation under saturation showed that this two-step triage protocol could have saved 28 to 40 more lives than no triage. Conclusion Although it cannot eliminate potentially avoidable deaths, this triage protocol proved able to adequately prioritize critical care for patients with highest probability of survival, hence to save more lives if applied.

Objectives:The clinical outcomes of the Beta (B.1.351) variant of concern (VOC) of the SARS-CoV-2 virus remain poorly understood. In early 2021, northeastern France experienced an outbreak of Beta that was not observed elsewhere. This outbreak slightly preceded and then overlapped with a second outbreak of the better understood VOC Alpha (B.1.1.7) in the region. This situation allowed us to contemporaneously compare Alpha and Beta in terms of the characteristics, management, and outcomes of critically ill patients.Methods:A multicenter prospective cohort study was conducted on all consecutive adult patients who had laboratory confirmed SARS CoV-2 infection, underwent variant screening, and were admitted to one of four intensive care units (ICU) for acute respiratory failure between January 9th and May 15th, 2021. Primary outcome was 60-day mortality. Differences between Alpha and Beta in terms of other outcomes, patient variables, management, and vaccination characteristics were also explored by univariate analysis. The factors that associated with 60-day death in Alpha- and Beta-infected patients were examined with logistic regression analysis.Results:In total, 333 patients (median age, 63 years; 68% male) were enrolled. Of these, 174 and 159 had Alpha and Beta, respectively. The two groups did not differ significantly in terms of 60-day mortality (19 vs. 23%), 28-day mortality (17 vs. 20%), need for mechanical ventilation (60 vs. 61%), mechanical ventilation duration (14 vs. 15 days), other management variables, patient demographic variables, comorbidities, or clinical variables on ICU admission. The vast majority of patients were unvaccinated (94%). The remaining 18 patients had received a partial vaccine course and 2 were fully vaccinated. The vaccinated patients were equally likely to have Alpha and Beta.Conclusions:Beta did not differ from Alpha in terms of patient characteristics, management, or outcomes in critically ill patients.Trial Registration:ClinicalTrials.gov, identifier: NCT04906850.

The COVID-19 health crisis has imposed an unprecedented adaptability of our health system. Intensive care units and emergency departments had to innovate and develop new strategies to guarantee quality care for patients needing intensive care. The "Grand-Est" region and particularly the counties of Moselle, Bas-Rhin and Haut-Rhin, were strongly impacted. Among the 349 patients transferred out of region, 164 were transferred to European countries (Austria, Germany, Luxembourg, and Switzerland) between March 14 and April 4, 2020. These international transfers, organized by the regional health agency and the emergency medical call centers, mainly use flying ambulances belonging to hospitals, army, and civil protection. The support of these patients was provided by a specialized physiciannurse team. The choice of this strategy made it possible to avoid saturation of intensive care units and to make a choice between patients admitted or not in intensive care. Adaptability of health care providers and an organization as close as possible to the field allowed these transfers to be carried out under good conditions. This episode demonstrates the importance of leaving the management of health crisis to health professionals. This article presents the organization set up to prepare and carry out these international transfers.

Background Acute respiratory distress syndrome continues to drive significant morbidity and mortality after severe trauma. The incidence of trauma-induced, moderate-to-severe hypoxaemia, according to the Berlin definition, could be as high as 45%. Its pathophysiology includes the release of damage-associated molecular patterns (DAMPs), which propagate tissue injuries by triggering neutrophil extracellular traps (NETs). NETs include a DNA backbone coated with cytoplasmic proteins, which drive pulmonary cytotoxic effects. The structure of NETs and many DAMPs includes double-stranded DNA, which prevents their neutralization by plasma. Dornase alfa is a US Food and Drug Administration-approved recombinant DNase, which cleaves extracellular DNA and may therefore break up the backbone of NETs and DAMPs. Aerosolized dornase alfa was shown to reduce trauma-induced lung injury in experimental models and to improve arterial oxygenation in ventilated patients. Methods TRAUMADORNASE will be an institution-led, multicentre, double-blinded, placebo-controlled randomized trial in ventilated trauma patients. The primary trial objective is to demonstrate a reduction in the incidence of moderate-to-severe hypoxaemia in severe trauma patients during the first 7 days from 45% to 30% by providing aerosolized dornase alfa as compared to placebo. The secondary objectives are to demonstrate an improvement in lung function and a reduction in morbidity and mortality. Randomization of 250 patients per treatment arm will be carried out through a secure, web-based system. Statistical analyses will include a descriptive step and an inferential step using fully Bayesian techniques. The study was approved by both the Agence Nationale de la Sécurité du Médicament et des Produits de Santé (ANSM, on 5 October 2018) and a National Institutional Review Board (CPP, on 6 November 2018). Participant recruitment began in March 2019. Results will be published in international peer-reviewed medical journals. Discussion If early administration of inhaled dornase alfa actually reduces the incidence of moderate-to-severe hypoxaemia in patients with severe trauma, this new therapeutic strategy may be easily implemented in many clinical trauma care settings. This treatment may facilitate ventilator weaning, reduce the burden of trauma-induced lung inflammation and facilitate recovery and rehabilitation in severe trauma patients. Trial registration ClinicalTrials.gov, NCT03368092 . Registered on 11 December 2017.

OBJECTIVE To compare incidence densities of methicillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBLE) acquisition in the intensive care unit (ICU) before and after discontinuation of contact precautions (CP) and application of standard precautions (SP). DESIGN Prospective noninferiority before-and-after study comparing 2 periods: January 1, 2012, to January 31, 2014 (the CP period) and February 1, 2014, to February 29, 2016 (the SP period). SETTING A 16-bed polyvalent ICU in France with only single-bed rooms with dedicated equipment and reusable medical devices. PATIENTS All patients admitted to the ICU during the CP and SP periods were included: 1,547 and 1,577 patients, respectively. METHODS Incidence densities of ICU-acquired MRSA or ESBLE were determined per 1,000 patient days. Other studied factors included (1) patient characteristics, (2) incidence densities of MRSA or ESBLE carried at admission, (3) compliance with hand hygiene protocols, and (4) antibiotic consumption. RESULTS Incidence densities of ICU-acquired MRSA were 0.82 (95% confidence interval [CI], 0.31–1.33) and 0.79 (95% CI, 0.30–1.29) per 1,000 patient days during the CP and SP periods, respectively. For ESBLE, values were 2.7 (95% CI, 1.78–3.62) and 2.06 (95% CI, 1.27–2.86) per 1,000 patient days. These rates were significantly nonsuperior during the SP period compared to CP period, with a margin of 1 per 1,000 patient days for both MRSA (P=.002) and ESBLE (P=.004). Other factors were comparable during the 2 periods. Only ESBLE carried at admission was inferior during the SP period. We observed a high level of compliance to hand hygiene protocols. CONCLUSIONS Discontinuing CP did not increase acquired MRSA and ESBLE in our ICU with single rooms with dedicated equipment, strict application of hand hygiene, medical and paramedical leadership, and good antibiotic stewardship. Infect Control Hosp Epidemiol 2017;38:1342–1350

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Background - Assessment of 20 months of work collaboration between intensive care unit (ICU) and mobile palliative care teams within the collegial group discussions prior to withholding or withdrawing treatments decisions defined in the Act of 22 April 2005.Objectives. - The research was designed: (1) to describe and to analyse the characteristics of patients receiving palliative care from mobile palliative care team; (2) to compare them with the other patients hospitalized in the ICU; (3) to describe the collaboration between mobile palliative care team and intensive care unit on withholding or withdrawing treatments.Method. - This was a single-centre retrospective study conducted in the intensive care unit of Metz-Thionville hospital; we enrolled all patients admitted in the ICU between January 1st, 2011 and December 31, 2012.Results. - The mobile palliative care team met 2.9% of 1256 patients admitted in the ICU during the study period. Patients met by the mobile palliative care team were significantly older, in a more serious condition at admission and hospitalized longer compared to the rest of patients admitted in the ICU. The collection of the patient's will was possible for 47.2% of them. Further to the intervention of the mobile palliative care team, it was decide to withdraw or withhold the treatment of 91.7% of the patients.Conclusion. - Mobile palliative care teams, although not seeming a classic interlocutor for the ICU, can play an important role by participating in the preliminary discussions to with holding or withdrawing treatments and by helping to support patients and their relatives. (C) 2015 Elsevier Masson SAS. All rights reserved.

L’œdème aigu pulmonaire (OAP) post-transfusionnel ou TACO, première cause de décès en transfusion en 2014, est probablement sous déclaré. Nous avons essayé d’améliorer la déclaration de cet évènement indésirable, grâce aux données du programme de médicalisation des systèmes d’information (PMSI) de notre établissement. Nous avons choisi d’utiliser le PMSI en plus des moyens habituels de recherche des TACO : déclaration spontanée, enquête sur les causes de destruction des produits sanguins labiles (PSL)… Le principe est de croiser sur un même séjour le code d’insuffisance cardiaque : I50.- en position de diagnostic associé significatif et un acte de transfusion. Ceci permet d’éliminer d’emblée les OAP de surcharge, autres que transfusionnels (diagnostic principal) et les OAP lésionnels. Cette recherche a été complétée en 2015 par l’ajout des diagnostics : insuffisance respiratoire aiguë (j96,0) et syndrome de détresse respiratoire chez l’adulte (j80). En 2014 sur 19 958 PSL transfusés : 9 TACO ont été identifiés dont 2 via les données du PMSI. En 2015 sur 19 907 PSL transfusés : 13 TACO dont 2 via le DIM. L’ajout des diagnostics j96,0 et j80 n’a pas permis d’identifier de cas supplémentaire. L’enquête via les données du PMSI ne peut se faire qu’en décalé (exhaustivité) et dépend de la qualité du codage par le médecin. Celui-ci ne cherche pas à cacher l’OAP puisqu’on le retrouve dans les dossiers et/ou les courriers de sortie, mais ne pense pas à le déclarer car ce n’est pas un problème dû à la qualité du produit. La requête via les données du PMSI a permis d’améliorer la notification des TACO dans l’établissement. Depuis la fin 2014, une grande campagne a été faite auprès des prescripteurs en s’appuyant sur les nouvelles recommandations HAS, améliorant encore les déclarations. L’étape suivante sera d’évaluer si cette sensibilisation contribue à diminuer le taux d’incidence des TACO ainsi détectés.

Respiratory complications of blood transfusion have several possible causes. Transfusion-Associated Circulatory Overload (TACO) is often the first mentioned. Transfusion-Related Acute Lung Injury (TRALI), better defined since the consensus conference of Toronto in 2004, is rarely mentioned. French incidence is low. Non-hemolytic febrile reactions, allergies, infections and pulmonary embolism are also reported. The objective of this work was to determine the statistical importance of the different respiratory complications of blood transfusion. This work was conducted retrospectively on transfusion accidents in six health centers in Champagne-Ardenne, reported to Hemovigilance between 2000 and 2009 and having respiratory symptoms. The analysis of data was conducted by an expert committee. Eighty-three cases of respiratory complications are found (316,864 blood products). We have counted 26 TACO, 12 TRALI (only 6 cases were identified in the original investigation of Hemovigilance), 18 non-hemolytic febrile reactions, 16 cases of allergies, 5 transfusions transmitted bacterial infections and 2 pulmonary embolisms. Six new TRALI were diagnosed previously labeled TACO for 2 of them, allergy and infection in 2 other cases and diagnosis considered unknown for the last 2. Our study found an incidence of TRALI 2 times higher than that reported previously. Interpretation of the data by a multidisciplinary committee amended 20% of diagnoses. This study shows the imperfections of our system for reporting accidents of blood transfusion when a single observer analyses the medical records.

"Transfusion-related acute lung injury" (TRALI) is a post-transfusion lesional pulmonary edema, potentially severe, better defined since the conference of Toronto in 2004. The incidence of TRALI reported in France remains low in part because of its ignorance by physicians. The objective of our study was to evaluate retrospectively transfusion accidents with respiratory complications that occurred in Nancy University Hospital and reported to the haemovigilance between 1996 and 2006, from the software "Traceline" listing all the blood transfusion complications from signs observed. The analysis of the files has been performed by applying rigorously diagnostic criteria of Toronto. Forty-one cases of respiratory complications were found in 34,573 blood products. Ten cases of TRALI were diagnosed while only one case had been reported to the haemovigilance. The remaining nine cases were previously labeled transfusion-associated circulatory overload (TACO). No cases of TRALI have been identified in the ICU. Our work can find an incidence of TRALI 10 times greater than previously reported. Ignorance of TRALI and the lack of consensus definition before 2004 are not sufficient to explain these results. This study demonstrates the potential interest of database and computerized declaration system based on the symptoms observed. It highlights the vulnerability of the current haemovigilance too dependent on a single medical observer. Although TRALI are recognized as serious complications, sometimes requiring resuscitative care, our work was not isolated severe TRALI in ICU. Physician awareness of TRALI to the identification and to the declaration, including ICU should be continued. Finally, the diagnostic criteria for TRALI must be adapted to the ICU. (c) 2013 Elsevier Masson SAS. All rights reserved.

Le transfusion-related acute lung injury (TRALI) est un œdème pulmonaire lésionnel post-transfusionnel, potentiellement grave, mieux défini depuis la conférence de Toronto de 2004. L’incidence des TRALI déclarés en France reste faible en partie à cause de sa méconnaissance par les praticiens. L’objectif de notre travail était d’évaluer de façon rétrospective les accidents transfusionnels avec complications respiratoires survenus au centre hospitalier universitaire de Nancy et déclarés à l’hémovigilance entre 1996 et 2006, à partir du logiciel « Traceline » répertoriant l’ensemble des complications de la transfusion sanguine à partir des signes observés. L’analyse des dossiers a été réalisée en appliquant de façon rigoureuse les critères diagnostiques de Toronto. Quarante et un dossiers de complications respiratoires ont été retrouvés pour 34573 produits sanguins administrés. Dix cas de TRALI ont été diagnostiqués alors qu’un seul un cas avait été déclaré auprès de l’hémovigilance de Nancy. Les neuf autres cas avaient été préalablement étiquetés transfusion-associated circulatory overload (TACO). Aucun cas de TRALI n’a été recensé en réanimation. Notre travail permet de retrouver une incidence des TRALI dix fois plus importante que celle déclarée auparavant. La méconnaissance des TRALI et l’absence de définition consensuelle avant 2004 ne suffisent pas à expliquer ces résultats. Cette étude montre l’intérêt potentiel d’une base de données et d’un système de déclaration informatisé et basé sur les symptômes observés. Elle met en lumière la vulnérabilité du système d’hémovigilance actuel beaucoup trop dépendant d’un observateur médical unique. Bien que les TRALI soient reconnus comme des complications graves nécessitant parfois des soins de réanimation, notre travail n’a pas isolé de formes sévères de TRALI en réanimation. La sensibilisation des médecins à l’identification des TRALI et à la déclaration, notamment en réanimation, doit être poursuivie. Enfin, les critères diagnostiques des TRALI doivent être adaptés à la réanimation.