Miseapnic

M.
SznajderP.
AegerterReplyReceived:9October1998Accepted:9October1998Sir:Wewerereallyinterestedbythecom-mentsofPautasandWysockiaboutthepa-perEstimationofdirectcostsandresourceallocationinintensivecare.
In1996weperformedanauditon215inten-sivecarestaysinallunitsofourcommondatabase[1]andfoundonthewholeabet-tercorrelationthanPautasetal.
[2].
Amethodologicalquestionisthatweonlycomputedcorrelationsbetweenthetwore-sults(thosefromthephysicianinchargeandthosefromthephysicianincontrol).
Calculatingtheamountofmedicalactivitylostthroughthegapbetweenthetwore-sultssupposesthattheindependentphysi-ciancontrollingthepatient'schartisagoldstandard,whichisquestionable.
Ofcoursethemoremissingitemsthereare,themorerelatedunitsarepenalizedfinan-cially.
However,anup-to-datemethodforresourceallocationinteachinghospitalin-tensivecareunitsisbaseduponnumberoffailures,throughrelevantOmegaitemsamongseveralparameters.
Inouraudit,thenumberofitemsaswellasthecalculationofscoresshowgoodreliabilityconcerningOmega1,Omega2,Omega3,totalOmega,lengthofventila-tion,intubation,failures:IntraclasscorrelationcoefficientsNo.
ofitemsScoresOmega10.
830.
85Omega20.
810.
90Omega30.
980.
97TotalOmega0.
96Durationofventilation0.
95KappaCirculatoryfailure0.
96Respiratoryfailure0.
64Renalfailure0.
88Intubation0.
91Anidenticalauditistobeperformedagaininthesameunits.
ThepoorimpactofcorrectivemeasuresmentionedbyPautasetal.
,evenatalocallevel,strengthenstheneedforrepeatedaudits,whicharegener-allycost-effective[3].
Amethodofprospectivequalitycon-trolisstillamajorissueassuggestedbyPautasandWysocki.
References1.
AegerterP,AuvertB,BuonamicoG,SznajderM,BeauchetA,GuidetB,LeGallJR,CubRea(1998)Miseenoeuvreetvaluationd'unebasededonnescommuneauxservicesderanimationd'Ile-de-France.
RevEpidemiolSantePublique46:226±2372.
PautasE,WysockiM,SuzanF,WolffMA,MilletH,HermanB(1995)Leser-reursderecueildanslecalculduscoreomega:frquenceetconsquences.
InActualitsenRanimationeturgen-ces,ReanUrg:7023.
NicolasF(1995)L'auditmdicalinternerptitifcommeinstrumentdematrisemdicalisedesdpenses.
InActualitsenRanimationeturgences,ReanUrg:123±131M.
Sznajder*P.
Aegerter())HopitalAmbroisePARE,Antenned'InformatiqueMdicale,9avenueC.
deGaulle,F-92104Boulogne,Francee-mail:philippe.
aegerter@apr.
ap-hop-paris.
frTel.
+33(1)49095669Fax+33(1)49095827F.
JardinHemodynamicprofileinsevereARDSReceived:6November1998Accepted:1December1998Sir:Ireadwithgreatinteresttherecentre-portbySquaraetal.
entitledHemody-namicprofileinsevereARDS[1].
Thistopicwasasubjectofinterestforourgroupinthe1980s[2]andwedescri-bedtheechocardiographicpatternofacutecorpulmonaleobservedinthisclin-icalsetting[3].
Initsmostsevereform,definedbyarightventricular/leftventri-cularend-diastolicarearatio>1onanapicalfour-chamberview,outcomewasalwaysfatal[3].
However,inamorere-centstudyofourechocardiographicdatainARDSpatients[4]wenoticedthatthissevereformwasnolongerobserved,sincetidalvolumehasbeenreducedfrom13ml/kgonaverageinthe1970s±1980sto8ml/kginthe1990s.
DatacollectedbySquaraetal.
involvedARDSpatientsmanagedbetweenSeptem-ber1985andMarch1987.
Atthistime,permissivehypercapniasuggestedin1990byHickling[5]wasnotyetused,andnor-mocapnicventilationwastherule.
Asamatteroffact,meanPaCO2inthepatientsenrolledinthisreportwas38.
1±8.
7mmHgandconfirmsthisstatement.
Peakairwaypressureusedduringrespira-torysupportinthesepatients(giveninTable3)isunexpected.
Inmyexperience,apeakairwaypressureat22.
8±7.
9cmH2OcannotrestorenormocapniainARDSpa-tients.
*Unfortunately,theauthorsdidnotmentionvaluesoftotalcompliance(CT)intheirpatients.
Withthismeanpeakairwaypressure,atidalvolumeof10ml/kg,asusedintheirstudy,andanaveragePEEPlevelat8.
4±4,onecaninferaplateaupressure60ml/cmH2Ointhemajorityofpatients,afind-ingunlikelyinARDSpatients.
Inarecentmulticenterstudydevotedtotidalvolumereduction,Brochardetal.
[6]foundanaverageplateaupressureat31.
7±6.
6cmH2OinthecontrolgroupofARDSpatientsreceivingmeantidalvolumeof10.
3±1.
7ml/kg(meanPaCO2at41.
3±7.
6mmHg).
Thus,Iamsomewhatcon-cernedaboutthepeakairwaypressurere-portedbySquaraetal.
[1].
ItseemsunlikelythatARDSpatientsexhibitingpulmonaryarterialhypertensionandfataloutcomehadbeenactuallyventilatedwithsuchalowairwaypressure.
AsaminorcommentIdrawtheatten-tionoftheauthorstothefactthatBenitoetal.
(reference30)didnotstudythepres-sure-volumeloopoftherightventricle,butthatofthewholelung.
References1.
SquaraP,DhainautJF,ArtigasA,CarletJetal.
(1998)HemodynamicprofileinsevereARDS:resultsoftheEuropeanCollaborativeARDSStudy.
IntensiveCareMed24:1018±10282.
JardinF,GurdjianF,FouilladieuJL,GoudotB,MargairazA(1979)Pulmo-naryandsystemicdisordersintheadultrespiratorydistresssyndrome.
IntensiveCareMed5:127±133246*Seeerratumonpage247.
3.
JardinF,GuretP,DubourgO,FarcotJC,MargairazA,BourdariasJP(1985)Two-dimensionalechocardiographicevaluationofrightventricularsizeandcontractilityinacuterespiratoryfailure.
CritCareMed13:932±9564.
JardinF,DubourgO,BourdariasJP(1997)Echocardiographicpatternofacutecorpulmonale.
Chest111:209±2175.
HicklingK,HendersonS,JacksonR(1990)Lowmortalityassociatedwithlowvolume/pressurelimitedventilationwithpermissivehypercapniainsevereadultrespiratorydistresssyndrome.
CriticalCareMed16:372±3776.
BrochardL,Roudot-ThoravalF,RoupieEetal.
(inpress)Tidalvolumereductionforpreventionofventilator-inducedlunginjuryintheacuterespiratorydistresssyndrome.
AmJRespirCritCareMed1998F.
JardinServicedeRanimationMdicale,HopitalAmbroisePar,9,avenueCharlesdeGaulle,F-92100Boulogne,FranceFax:+33(1)49095892P.
SquaraJ.
-F.
A.
DhainautA.
ArtigasJ.
CarletandtheEuropeanCollaborativeARDSWorkingGroupHemodynamicprofileinsevereARDS:resultsoftheEuropeanCollaborativeARDSstudyIntensiveCareMed(1998)24:1018±1028Intheaboveoriginalarticleinissueno.
10,inthecaptionofTable3Pawwasincorrectlydefinedaspeakairwaypressure;thisshouldreadmeanairwaypressure(peakPawforallpatientswas3910cmH2O).
247ERRATUM