According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao
 2/Fio
 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao
 2/Fi
 o
 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

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Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

2018 ESC/ESH Guidelines for the management of arterial hypertension.

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

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Publisher Correction to: Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross‑over randomized controlled trial E‑CHOISIR (Electronic‑CHOIce of a System for Intensive care Relaxation)

Patients and Methods A multicenter randomized controlled trial of 128 intubated adults (median [IQR] age, 66 [57-77] years) was conducted in 11 intensive care units in France from April 2010 to June 2012. Patients were included as soon as they could tolerate PSV with a PS level ≤30 cmH2O, a PEEP ≤8 cmH2O and a FiO2 ≤50%. Patients were randomly assigned to NAVA (n = 62) or PSV (n = 66). The PS level in the PSV group and the NAVA level in the NAVA group were set to obtain a tidal volume of 6-8 ml/kg. The primary end point was the probability to remain in an assist mode during the entire first 48 hours. Secondary end points were duration of mechanical ventilation and 28 days mortality. Results 67.2% (n = 45) in the NAVA group vs. 63.3% (n = 44) in the PSV group (p = 0.66).. The time spend in an assist mode during the first 48 hours was 47 [43-48] hours in the NAVA group vs. 47 [40-48] hours in the PSV group (p = 0.55). The asynchrony index was lower in the NAVA group (19.7% vs. 32.6%), so was the prevalence of dyspnea at day-1 (9% vs. 19%). The time to first extubation was 7 [2-10] days in the NAVA group vs. 7 [2-10] days in the PSV group (p = 0.78). The hospital mortality rate in the NAVA group was 14.5% (n = 9) vs. 21.2% (n = 14) in the PSV group (p = 0.2). NAVA and PSV were associated to similar oxygenation. NAVA was not associated with any adverse event.

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Comparison of neurally adjusted ventilatory assist and pressure support ventilation during the early phase of weaning from mechanical ventilation - a randomised controlled study

Resume Objectifs Evaluer la faisabilite et la fiabilite de l’utilisation du masque larynge renforce (MLR) lors de la chirurgie reparatrice de sequelles de brulures, avec prise de greffe cutanee sur le cuir chevelu Type de l’etude Etude prospective observationnelle, descriptive Patients et methodes Apres avis du comite d’ethique local, 26 patients ont ete inclus lors de la consultation anesthesique Apres induction d’une anesthesie generale, un MLR etait mis en place Le nombre de tentatives de mise en place du masque, la pression de fuite, le volume courant et la pression de CO2 dans le gaz expire etaient releves lors de cinq positions differentes de la tete (neutre, hyperflexion, hyperextension, rotation a droite puis a gauche) au debut et a la fin de l’intervention Au total dix periodes de deux a trois minutes chacune ont ete evaluees Resultats L’insertion du masque a ete facile dans 100 % des cas Comparee a la position de reference (tete neutre en debut d’intervention), la pression de fuite (27,9 ± 8,1 cmH2O) augmentait significativement en hyperflexion (33,3 ± 7,3 cmH2O, p  Conclusion L’utilisation du MLR au cours de la chirurgie reparatrice de brulures, avec mobilisation de la tete pour prelevement de greffe cutanee sur le cuir chevelu est faisable

Intérêt du masque laryngé renforcé au cours de la chirurgie réparatrice chez les patients brûlés nécessitant une mobilisation de la tête : étude de faisabilité

Numerous studies emphasize the application of music therapy and music medicine in the treatment of pain. The MUSIC CARE© app that was designed at the University Hospital of Montpellier applies the U-shape music composing technique taking into account the available evidence of the literature on relaxation paradigms. The main objective of this article is to summarize recent research on the standardization and evaluation of this new app of music medicine in the treatment of pain. Following a comprehensive review of the literature, a series of controlled, randomized, multi-centered studies were conducted including patients seeking care in such diverse setting as rheumatology, functional rehabilitation, oncology, geriatrics, anesthesiology and intensive care, neurology, obstetrics, pediatrics and general pain treatment. The effect of the MUSIC CARE© app has been evaluated on different types of acute and chronic pain of various origins (i.e. mechanical, inflammatory and neurological fibromyalgia). Physiological effects on hemodynamic and respiratory markers as well as psychological outcomes, including the relationship between care-provider and patient have been emphasized within multiple trials. The MUSIC CARE© app reduces pain, anxiety and depression to a significant degree and decreases the need for anxiolytics and antidepressants. Our first randomized controlled trials demonstrate the benefit of using MUSIC CARE© application in the management of pain. Future directions for the use of the app in various settings are discussed.

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/pdf/pressure-support-ventilation-in-the-operating-room-22w8kg547l.pdf

Samir Jaber

Papers

Publisher Correction to: Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross‑over randomized controlled trial E‑CHOISIR (Electronic‑CHOIce of a System for Intensive care Relaxation)

Comparison of neurally adjusted ventilatory assist and pressure support ventilation during the early phase of weaning from mechanical ventilation - a randomised controlled study

Intérêt du masque laryngé renforcé au cours de la chirurgie réparatrice chez les patients brûlés nécessitant une mobilisation de la tête : étude de faisabilité

Evaluation of the Standardized MUSIC CARE© App in the Treatment of Pain: The U-Shape Composing Technique

Pressure-support Ventilation in the Operating Room