Gérald Chanques

Les patients hospitalisés en réanimation présentent fréquemment des troubles neurologiques (troubles de la vigilance, troubles du sommeil, dysfonctions cognitives multiples, confusion mentale), psychologiques (anxiété, dépression, syndromes délirants), des syndromes douloureux et de l'inconfort. Ces troubles ont en commun : la problématique de leur définition et de leur reconnaissance par l'équipe de réanimation, leur expression fréquente par un comportement d'agitation, une association avec la réponse de stress post-agressive rencontrée au cours des pathologies traitées en réanimation. La physiopathologie de ces troubles est complexe, impliquant à la fois la pathologie qui a déterminé l'hospitalisation du patient en réanimation, ses antécédents médicaux, mais aussi la réanimation elle-même par les thérapeutiques invasives qui y sont utilisées, ainsi que la sédation médicamenteuse ou le coma artificiel. En outre, ces troubles peuvent être associés dans leur expression comme dans leur détermination, certain pouvant être cause ou conséquence d'un autre. L'objectif de cette thèse était de montrer qu'une prise en charge diagnostique et thérapeutique rationalisée de la douleur, des troubles neurologiques et psychologiques était associée à un meilleur pronostic du patient en réanimation.

Purpose Whether dexmedetomidine improves the control of hyperactive delirium in non-intubated intensive care unit (ICU) patients as compared with placebo remains uncertain. Methods In a multicenter, double-blind, placebo-controlled, two-arm, investigator-initiated, randomized trial conducted in 9 ICUs, we randomly assigned non-intubated critically ill adults with hyperactive delirium to receive continuous intravenous infusion of dexmedetomidine or placebo for at least 36 h. The primary outcome was a joint modelling of multiple outcomes of agitation duration (score of + 1 or higher on the Richmond agitation-sedation scale), delirium duration, or the need for intubation and deep sedation. Key secondary outcomes included the occurrence of complications (such as bradycardia or hypotension), length of stay in ICU, or death. Results Enrollment occurred from December 2017 to February 2022. Final follow-up was in February 2023. The study was stopped for efficacy at the time of the preplanned interim analysis. Among the 151 patients who were included in the final analysis, the between-group difference in the primary outcome was statistically significant (median difference, -30 points; 95% CI, − 49 to − 12, p = 0.001). Agitation duration was shorter in the dexmedetomidine group (1.0 (1.0–2.0) vs 2.0 (1.0–7.0) hours, absolute difference 95% CI − 1.0 (− 2.0 to − 0.1); ES, − 0.60; 95% CI, -0.92 to -0.27, p = 0.001). Other key secondary outcomes were similar between groups. Conclusion In non-intubated adult ICU patients with hyperactive delirium, the use of dexmedetomidine was associated with a greater clinical benefit than placebo for the joint modelling of multiple endpoints of agitation control, delirium resolution, and intubation with mechanical ventilation. Dexmedetomidine appears to be a valuable alternative that significantly reduced the median duration of agitation by approximately 1 h compared to placebo in hyperactive delirious non-intubated intensive care unit patients. Trial Registration: ClinicalTrial.gov Identifier: NCT03317067. Registration on October 17th, 2017 prior to first patient inclusion. https://clinicaltrials.gov/search?term=NCT03317067.

Summary: Introduction: Extubation of the trachea in the operating theatre may increase the time spent there. Conversely, tracheal extubation in the post‐anaesthesia care unit may prolong the duration of anaesthesia and increase the incidence of complications. Our primary objective was to quantify the additional occupancy time associated with tracheal extubation in the operating theatre compared with the post‐anaesthesia care unit. Secondary objectives were to assess the incidence of complications after tracheal extubation, including the need for ventilatory support. Methods: This was a prospective dual‐centre observational cohort study of patients whose tracheas were intubated for surgery in the operating theatre of two university hospitals. The primary endpoint was operating theatre occupancy time between the end of surgical procedure and discharge from the operating theatre. Results: In total, 756 patients were included, and 494 (65.3%) tracheal extubations occurred in the operating theatre. Room occupancy time was increased by 7 min (95%CI 5–8 min, p = 0.001) when tracheal extubation was performed in the operating theatre compared with the post‐anaesthesia care unit. After adjustment by matched or weighted propensity score, this time increased to 8 min (95%CI 6–10 min, p = 0.001) and 8 min (95%CI 6–9 min, p = 0.001), respectively. Desaturation after tracheal extubation (20.9% vs. 36.3%, p < 0.001) and arterial hypotension (0.6% vs. 3.1%, p = 0.019) were less frequent when tracheal extubation took place in the operating theatre. Discussion: Tracheal extubation in the operating theatre is associated with an increase in theatre occupancy of < 8 min and a lower incidence of postoperative respiratory and cardiovascular complications.

Rationale: When compared with VenturiMask after extubation, high-flow nasal oxygen provides physiological advantages. Objectives: To establish whether high-flow oxygen prevents endotracheal reintubation in hypoxemic patients after extubation, compared with VenturiMask. Methods: In this multicenter randomized trial, 494 patients exhibiting PaO2:Fi O2 ratio ⩽ 300 mm Hg after extubation were randomly assigned to receive high-flow or VenturiMask oxygen, with the possibility to apply rescue noninvasive ventilation before reintubation. High-flow use in the VenturiMask group was not permitted. Measurements and Main Results: The primary outcome was the rate of reintubation within 72 hours according to predefined criteria, which were validated a posteriori by an independent adjudication committee. Main secondary outcomes included reintubation rate at 28 days and the need for rescue noninvasive ventilation according to predefined criteria. After intubation criteria validation (n = 492 patients), 32 patients (13%) in the high-flow group and 27 patients (11%) in the VenturiMask group required reintubation at 72 hours (unadjusted odds ratio, 1.26 [95% confidence interval (CI), 0.70–2.26]; P = 0.49). At 28 days, the rate of reintubation was 21% in the high-flow group and 23% in the VenturiMask group (adjusted hazard ratio, 0.89 [95% CI, 0.60–1.31]; P = 0.55). The need for rescue noninvasive ventilation was significantly lower in the high-flow group than in the VenturiMask group: at 72 hours, 8% versus 17% (adjusted hazard ratio, 0.39 [95% CI, 0.22–0.71]; P = 0.002) and at 28 days, 12% versus 21% (adjusted hazard ratio, 0.52 [95% CI, 0.32–0.83]; P = 0.007). Conclusions: Reintubation rate did not significantly differ between patients treated with VenturiMask or high-flow oxygen after extubation. High-flow oxygen yielded less frequent use of rescue noninvasive ventilation. Clinical trial registered with www.clinicaltrials.gov (NCT02107183).