Intensive Care Med (2008) 34:13931400

DOI 10.1007/s00134-008-1059-y ORIGINAL

Jean-Pierre Quenot
Herv Mentec
Bedside adherence to clinical practice
Franois Feihl guidelines in the intensive care unit:
Djillali Annane
Christian Melot the TECLA study
Philippe Vignon
Christian Brun-Buisson
TECLA Study Group

Received: 4 January 2007
Accepted: 27 January 2008
Published online: 26 March 2008
Springer-Verlag 2008
The full list of investigators participating in
the TECLA study appears under Acknowl-
edgements.
J.-P. Quenot (u)
Hpital Bocage, Service de Ranimation
Mdicale,
2 Boulevard Marchal de Lattre de
Tassigny, BP 77908, 21079 Dijon, France
e-mail: jean-pierre.quenot@chu-dijon.fr
Tel.: +33-380-293751
Fax: +33-380-293807
J.-P. Quenot H. Mentec F. Feihl
D. Annane C. Melot P. Vignon
C. Brun-Buisson
Socit de Ranimation de Langue
Franaise, Commission dEpidmiologie
et de Recherche Clinique,
Paris, France
Abstract Objective: To assess ad- who were not treated 28 (10%) had
herence to clinical practice guidelines an indication. Conclusions: The
for three interventions routinely used implementation of recommendations
in critical care medicine. Design and varies across different domains of
setting: Multicenter, 1-day cross- care. While the adherence to current
recommendations in routine practice
sectional observational study in 44
intensive care units in four countries. is acceptable as regards tidal volume
Patients: A total of 419 patients hos- settings in acute respiratory distress
pitalized in participating ICUs on the syndrome, it is suboptimal for blood
day of the survey. Measurements and transfusion and prevention of upper
results: Red blood cell transfusion gastrointestinal bleeding. Practice
(n = 29) was performed appropriately surveys are useful to inform strate-
in 22 patients (76%), while among the gies currently developed to assess
390 patients who received no trans- practices of health-care profession-
als and develop strategies for more
fusion 4 (1%) had a valid indication.
Setting of tidal volume in acute respi- effective dissemination of medical
ratory distress syndrome, assessed in knowledge.
45 patients, was deemed appropriate
in 37 cases (82%). Prescription of Keywords Transfusion Practice
stress ulcer prophylaxis (n = 128) guidelines Respiratory distress
was appropriate in only 24 patients syndrome Stress ulcer prophylaxis
(19%), while among the 268 patients Intensive care

Introduction can be facilitated by evaluating the impact of applying

Clinical research studies are an indispensable tool for
improving medical knowledge and improving practice in
intensive care units (ICUs) [1, 2]. However, translating
the results of clinical research into actual clinical practice
is a complex process [3]. The first step in this process is
the publication of data generated from clinical studies.
However, only one-third of completed clinical trials are
eventually published, predominantly those reporting posi-
tive results [4, 5] (Clinical trials gov, Linking patients to
medical research, http://www.clinicaltrials.org; Current
controlled trials, Featuring the metaregister of controlled
trials, http://www.controlled-trials.com). Although the
implementation of research results into clinical practice
new approaches through large-scale epidemiological sur-
veys [68], the quantity of scientific information published
is so huge that it renders valuable information inaccessible
for most physicians. For this reason official health organi-
zations, scientific societies, and international collaborative
groups such as the Cochrane Collaboration provide
summaries of the best evidence on specific interventions,
and these summaries are of paramount importance for
disseminating medical knowledge. Finally, even when the
information is delivered to the target physicians, several
hurdles limit the uptake of specific recommendations into
routine practice, including difficulty in changing behavior,
an inadequate environment, and factors related to cost or
cultural issues.
1394

A number of interventions in critical care medicine (n = 17, 39%), general (nonacademic) hospitals (n = 25,
have recently been scrutinized, and several clinical trials 57%), or semiprivate hospitals (n = 2, 4%). There were
performed to assess their clinical impact. For example, red 36 (82%) mixed medicosurgical, 4 (9%) surgical, and 4
blood cell transfusions are a cornerstone of critical care (9%) medical ICUs. Six hospitals had two separate ICUs
practice, but there are divergent views on the risks of ane- participating in the study. Three units (8%) had 6 beds or
mia and the benefits of transfusion in this setting. A recent fewer, 32 (71%) had between 7 and 15 beds, and 9 (21%)
controlled trial of red blood cell transfusion in critical care had more than 15 beds. The median number of admissions
showed that a restrictive strategy is at least as effective as per year in the participating ICUs was 437 (2581215).
(and possibly superior to) a more liberal strategy [9], and There was no difference between participating centers and
several clinical practice guidelines have been issued to nonresponders as regards size, academic status, and main
recommend a conservative transfusion policy, restricting activities. Since this observational study required no de-
transfusion to patients having hemoglobin levels below viation from routine medical practice, institutional review
7 g/dl. board approval was not required. The study was approved
In the setting of acute respiratory distress syndrome by the SRLF Ethics Committee. Physicians collecting the
(ARDS) the mortality rate is approx. 4050% [10, 11]. data were blinded to the main objective of the study.
Mechanical ventilation using large tidal volumes can cause
the disruption of pulmonary epithelium and endothelium,
lung inflammation, atelectasis, hypoxemia, and the release Patient population
of inflammatory mediators [12, 13]. There is some evi-
dence from the medical literature that a lower tidal volume All 419 adult patients present in the ICUs of the participat-
(68 ml/kg) than is traditionally used (1012 ml/kg) may ing centers on the data collection day were eligible except
reduce mortality [14]. These studies demonstrate that the those with a do-not-resuscitate order or any other decision
adoption of target values in clinical practice results in ben- to withdraw or withhold therapy in the ICU. Patients
eficial outcomes to patients. On the other hand, while the who were intubated and receiving mechanical ventilation
use of stress ulcer prophylaxis is very common in critical were included in the evaluation of tidal volume settings
care medicine, there is little evidence that this intervention if they had clinical and radiographic features of ARDS,
influences patients outcomes, and its use is recommended i.e., an acute decrease in the ratio of partial pressure of
only in selected groups of patients with multiple risk fac- arterial oxygen to fraction of inspired oxygen (PaO2 /FIO2
tors for bleeding [15]. ratio) of 250 or less, bilateral pulmonary infiltrates on
To assess the translation of clinical research into
routine critical care practice we assessed the current use of
these three interventionsred blood cell transfusion, tidal Table 1 Clinical characteristics of the study population (n = 419)
volumes in ARDS, and stress ulcer prophylaxisthrough
Age, median (years; range) 61 (1692)
a multicenter, cross-sectional study. Preliminary results Gender: M/F 291/128
were presented at the 32th Congress of the Socit de Admission category
Ranimation de Langue Franaise (SRLF, French-speak- Medical 277 (66%)
ing Society of Intensive Care) in Paris, January 2005. Unscheduled surgery 85 (20%)
Scheduled surgery 37 (9%)
Trauma 20 (5%)
Transfer to ICU from
Materials and methods Emergency room 141 (34%)
Study design Medical ward 135 (33%)
Surgical ward 78 (19%)
Operating/recovery room 37 (9%)
The TECLA survey was a multicenter, cross-sectional, ob- Another ICU 28 (7%)
servational study conducted in ICUs in France, Belgium, Comorbidities
Canada, and Switzerland. The study consisted of a 1-day Immunodepression 35 (8.3%)
cross-sectional recording of all interventions performed Metastatic cancer 18 (4.3%)
Hematological malignancy 1 (0.2%)
and treatments administered to all patients hospitalized Acquired immunodeficiency syndrome 5 (1.2%)
in the participating ICUs on 11 May 2004. A total of Chronic respiratory insufficiency 52 (12%)
630 critical care physicians representing 120 ICUs were Chronic heart failure 44 (10%)
invited to participate by means of a mail request through Type I diabetes 20 (4.7%)
Chronic liver failure 9 (2%)
the SRLF website. The recruitment of participating ICUs Chronic renal failure 11 (2.6%)
was on a voluntary basis, from a mailing list, with no McCabes classification
financial incentive. A total of 44 units (37%) agreed to No underlying disease affecting prognosis 238 (57%)
participate in the study, involving in total 103 physicians Ultimately fatal (< 5 years) 128 (30%)
in 38 hospitals (see Acknowledgements). The partici- Rapidly fatal (< 1 year) 53 (13%)
SAPS II score at admission, median (range) 38 (0112)
pating ICUs were university and/or regional hospitals

chest radiography consistent with the presence of edema,
and no clinical evidence of left arterial hypertension or
a pulmonary-capillary wedge pressure of 18 mmHg or
less (if measured). Patients were excluded if they had
increased intracranial pressure, pregnancy, vasculitis
with diffuse alveolar hemorrhage, or if they had received
a bone marrow or lung transplant. The predicted body
weight (PBW) was calculated as 50 +0.91 [height (cm)
152.4] in men and as 45.5 +0.91 [height (cm) 152.4]
in women. All patients were included in the evaluation
of blood transfusion practices according to hemoglobin
concentrations except those having chronic anemia,
pregnancy, bone marrow transplantation, or leukemia.
Patients were excluded from the evaluation of stress ulcer
prophylaxis if they were being previously treated for
gastrointestinal (GI) ulcer before ICU admission or had
had a gastrectomy.
Fig. 1 Algorithm for red blood
cell transfusion. HR, Heart rate
1395
Patients median age was 61 years (range 1692), and
median Simplified Acute Physiology Score (SAPS) II on
ICU admission was 38 points (range 0112; Table 1). Med-
ical patients represented 66% of the patient population,
surgical 29%, and trauma 5%. By the McCabe classifica-
tion, 57% of patients had no preexisting underlying dis-
ease likely to affect prognosis, while 13% had a rapidly
(< 1 year) fatal disease.
Data collection
The following data were recorded: age, weight, height,
admission diagnosis, SAPS II score on admission [16],
vital signs and standard laboratory data on the day of
survey, details of any intervention or treatment including
administration of drugs, blood products and nutrition,
1396
or ventilatory, circulatory, and renal support, noting the
indication for each intervention. One physician in each
participating ICU was in charge of completing the data
collection.
The standards for each of the three interventions under
study relied on data from published original papers and
from available guidelines generated by official health
organizations or scientific societies. The pivotal TRICC
study [9] and recommendations from both the Agence
Franaise de Scurit Sanitaire des Produits de Sant
(French Health Products Safety Agency, Transfusions
de globules rouges homologues: produits, indications,
alternatives, http://www.anaes.fr) and the SRLF con-
sensus conference [XXIII confrence de consensus en
ranimation et mdecine durgence: transfusion ry-
throcytaire en ranimation (nouveau-n exclu), 2003,
http://www.srlf.org] were used to establish standards of
care for blood transfusion in the critically ill. For stress
ulcer prophylaxis we used recently published original
articles [1721] and the revised guidelines of the con-
sensus conference of the SRLF [15]. For the setting of
tidal volume in ARDS we established our own standard
of care partly on the basis of the pivotal ARDS Net-
Fig. 2 Algorithm for tidal
volume in ARDS
Work study [14] and the recommendations of the SRLF
expert group (J.C. Richard, C. Girault, S. Leteurtre, F.
Leclerc, Groupe dexpert de la SRLF, Prise en charge
ventilatoire du syndrome de dtresse respiratoire aigu
de ladulte et de lenfant (nouveau-n exclu), 2005,
http://www.srlf.org) which were under development at
the time of study. The appropriateness of the prescription
of the three therapeutic interventions under study was
assessed according to algorithms developed by the SRLF
Commission for Epidemiology and Clinical Research
(Commission dEpidemiologie et de Recherche Clinique)
(Figs. 1, 2, 3).
Data evaluation and quality control
Data were collected in each ICU by experienced physi-
cians using standardized electronic case report forms and
automatically entered into a computer program. The pro-
gram included reliability checks based on ranges for phys-
iological and biological data, and logical checks for incon-
sistencies and missing data. Extensive data cleaning was
carried out by the Steering and the Writing Committees,

Fig. 3 Algorithm for stress ulcer
prophylaxis. ACT, Activated
clotting time; ISS, Injury
Severity Score; GCS, Glasgow
Coma Score
including queries addressed to the investigators for ques- specific explanation was found to justify this prescription.
tionable or missing data. The results are expressed as pro- Of the 390 patients who did not receive red blood cell
portional values for qualitative variables.
Results
Prescription of red blood cell transfusion
Of the 419 patients assessed for eligibility two were
excluded because of chronic anemia or leukaemia.
Among the 417 patients included in the final evaluation
of red blood cell transfusion prescriptions, the average
hemoglobin concentration was 10.8 0.9 g/dl. Twenty-
nine patients (7%) received at least one pack of red blood
cells on the study day. In 19 patients the transfusion was
justified by a hemoglobin level less than 7 g/dl (average
6.1 0.5 g/dl) associated with hemorrhagic shock and
acute hemorrhage in the context of multiple trauma or GI
bleeding. In a further three patients the main reason for
transfusion was a hemoglobin level between 7 and 10 g/dl
(average 7.9 0.7 g/dl) in the context of acute coronary
insufficiency (n = 2) or the early therapy of septic shock
(n = 1). According to our predefined algorithm (Fig. 1),
transfusion was deemed appropriate in these 22 (76%)
patients. Seven remaining patients (24%) received inap-
propriate red blood cell transfusion. In these patients
the average hemoglobin level was 7.8 0.3 g/dl, but no
1397
transfusion four (1%) had a hemoglobin level below
7 g/dl and should have been transfused but were not; no
explanation was given as to why they did not receive blood
transfusion (Table 2).
Tidal volume in ARDS
Of the 419 patients assessed for eligibility 229 (55%) were
receiving mechanical ventilation on the study day. We
evaluated ventilatory settings in 45 of these patients (20%)
who had a reported diagnosis of ARDS, and in whom
PBW could be calculated (two patients were excluded
because one patient presented with elevated intracranial
pressure and another patient had a lung transplant). The
volume-assist control mode was used for the majority of
patients receiving mechanical ventilation and all patients
Table 2 Appropriateness of red blood cell transfusion in 417 pa-
tients according to treatment algorithm (Fig. 1) developed from the
medical literature
Red blood cell transfusion Yes (n = 29) No (n = 390)
Indication present 22 (76%) 4 (1%)
No indication present 7 (24%) 386 (99%)
1398
Table 3 Appropriateness of stress ulcer prophylaxis in 396 patients The very low rate of transfused patients bears witness
according to treatment algorithm (Fig. 3) developed from the medi- to this reticence. The salient message from the report by
cal literature
Stress ulcer prophylaxis Yes (n = 128) No (n = 268)
Indication present 24 (19%) 28 (10%)
No indication present 104 (81%) 240 (90%)
with ARDS. The mean tidal volume in patients with
ARDS was 7.2 0.5 ml/kg PBW and mean plateau
pressure was 28 5 cmH2 O. According to our predefined
algorithm (Fig. 2), tidal volume setting was considered
appropriate in 37 of 45 patients (82%) with ARDS. In the
8 patients (18%) receiving inappropriate tidal volume
the average tidal volume was 8.8 0.6 ml/kg PBW and
plateau pressure 35 4 cmH2 O.
Prescription of stress ulcer prophylaxis
Of the 419 patients assessed for eligibility in the evalu-
ation of prescription of stress ulcer prophylaxis 23 were
excluded because they had previously been treated for gas-
troduodenal ulcer with proton pump inhibitor therapy (11
before admission to the ICU and 12 during ICU stay). Of
the 396 remaining patients 128 (32%) received preventive
therapy for upper GI bleeding: 85 (67%) a proton pump
inhibitor, 27 (21%) an H2 -receptor antagonist (ranitidine),
and 16 (12%) sucralfate. According to our algorithm
(Fig. 3), the prescription was appropriate in only 24 (19%)
of these 128 patients, and thus the remaining 104 (81%)
patients were treated unnecessarily. Conversely, among
the 268 patients who were not treated, an indication for
stress ulcer prophylaxis was present in 28 (10%; Table 3).
Discussion
This is the first study to assess the bedside application
of research results from the medical literature for three
frequently used interventions in critically ill patients,
including transfusion of red blood cells, low tidal volume
in ARDS, and preventive therapies for upper GI bleeding.
The main finding of our study is the relatively high rate of
appropriateness as regards tidal volume settings, but the
adherence to recommendations for blood transfusion and
stress ulcer prophylaxis was mediocre.
This discrepancy between the adherences to guidelines
for these interventions may result from numerous factors.
Firstly, the nature of the intervention may impact on its
use. Red blood cell transfusion is considered to be poten-
tially associated with serious adverse events, particularly
in France since the blood contamination scandal in the
1990s. Since then the use of blood transfusion has been
severely restricted by French regulatory authorities, and
physicians are reluctant to prescribe blood transfusions.
Hebert et al. [9] was that a restrictive blood transfusion
policy impacts favorably on ICU patients outcome,
which corresponds to physicians beliefs, making them
more inclined to recommend this policy. Furthermore,
some hospitals may have a stronger tradition of applying
clinical practice guidelines. A recent study [22] conducted
among Canadian critical care practitioners evaluated red
cell transfusion practice in the critically ill and examined
changes in practice over time. In this study there was
a significant decrease in transfusion and use of single-unit
transfusion over time. Nonetheless, almost one quarter
of the transfusions carried out on the day of our study
were performed unnecessarily. Increased awareness of the
indications for blood transfusion and the potential adverse
effects could help to reduce the number of unnecessary
transfusions over time.
Concerning tidal volume in ARDS, adoption of the
low tidal volume strategy has been slow even in centers
having participated in the ARDSNet trial, as demonstrated
by Weinert et al. [23]. On the other hand, physicians
in Europe [23] may have more easily endorsed the rec-
ommendation because patients with ARDS appeared to
have been more routinely treated with much lower tidal
volumes [2426]. Secondly, the simplicity of the recom-
mendation is also of paramount importance, as shown by
the relatively good level of application of standards for
blood transfusion and tidal volume in ARDS. Thirdly,
the robustness of the recommendation may also influence
the level of uptake by physicians, as shown in this study
for stress ulcer prophylaxis, where 81% of patients
were treated unnecessarily. It should be noted that this
intervention differs from the other two in that it concerns
drugs for which the potential influence of industry-driven
recommendations (for example, for a larger use of proton
pump inhibitors) is more likely than for the other two
interventions under study. Admittedly, there are few recent
data in the literature [1721] concerning this intervention,
an important factor that needs to be taken into account
when evaluating the appropriateness of prescription. In
addition, the low cost of these drugs encourages wider use.
One reason for the poor adherence to recommenda-
tions in this area is the inconsistency of data from the lit-
erature and the lack of a strong consensus on which ICU
patients should receive prophylaxis. In addition, the per-
ceived low consequences of GI bleeding relative to other
complications which may occur during ICU care could en-
courage physicians not to devote much attention to this
problem and its prevention. A recent study [27] demon-
strated that no single strategy of stress ulcer prophylaxis
is preferred when mortality is used as the outcome. Piti-
mana et al. [28] demonstrated that the implementation of
clinical practice guidelines for stress ulcer prophylaxis in-
creased the appropriateness of prescription (from 75.8%
to 91.1%) and decreased the cost of care, but without sig-
 1399

nificant impact on clinical outcomes. In the absence of was performed appropriately in the majority of patients,
a clinical trial demonstrating survival benefit the individual but a considerable proportion of patients were transfused
clinicians assumptions regarding the effect of prophylaxis unnecessarily. Similarly, stress ulcer prophylaxis is also
on GI bleeding and potentially increased risk of pneumo- less well implemented. Translation of research results into
nia, as well as consideration of the attributable mortality actual clinical practice at the bedside faces various hur-
of pneumonia vs. GI bleeding, are likely to impact sub- dles which may differ according to specific interventions.
stantially on physicians attitudes and decisions [20, 29]. Practice surveys are useful to inform strategies currently
Lastly, the experienced practitioners may be aware of cur- developed to assess practices of health-care professionals
rent research but have defensive objections to treating pa- and develop strategies for more effective dissemination of
tients with a protocol that minimizes their ability to adjust medical knowledge, and ultimately improve management
therapy based on an individuals physiology, or may be- and outcomes of patients.
lieve their patients condition is not representative of those
Acknowledgements. TECLA Steering Committee members
in clinical trials [30]. were: F. Feihl, MD, H. Mentec, MD, D. Annane, MD, PhD,
There are several potential limitations associated with C. Brun-Buisson, MD, PhD, C. Melot, MD, PhD, P. Vignon,
the methods used in this study, including social responses MD, PhD. Members of the Epidemiology and Clinical Research
bias and the response rate. An acceptable proportion (44 Commission (Commission dEpidemiologie et de Recherche
centers, 37%) of all centers contacted agreed to participate. Clinique) were: Herv Mentec (Argenteuil, France), Djillali Annane
(Garches, France), Pascal Beuret (Roanne, France), Julien Boh
Naturally, this relatively good participation rate provides (Lyon, France), Bernard Bouffandeau (Elbeuf, France), Fabrice
significant potential for bias, as there is a concern that only
Bruneel (Versailles, France), Christian Brun-Buisson (Crteil,
the high-performing, highly motivated centers will engage France), Yves Cohen (Bobigny, France), Robin Cremer (Lille,
in such a study. This would further bias the results towards France), Franois Feihl (Lausanne, Switzerland), Bertrand Guidet
(Paris, France), Merc Jourdain (Lille, France), Jean-Michel Liet
an overestimation of compliance with guidelines in that (Nantes, France), Christian Melot (Brussels, Belgium), Mehran
the participating units may favor high-performing, quality Monchi (Massy, France), Jean-Charles Preiser (Liege, Belgium),
ICUs. This percentage of participation may be explained in Jean-Pierre Quenot (Dijon, France), Jean-Philippe Rigaud (Dieppe,
part by the fact that the main objective of the study (namely France), Marie-Denise Schaller (Lausanne, Switzerland), Philippe
Vignon (Limoges, France), Christophe Vinsonneau (Paris, France).
to evaluate routine practice with respect to three specific Participants by country (listed alphabetically) were: France:
interventions) was not stated in the first phase of the study C. Galland, Saint-Omer Hospital; C. Brun-Buisson, Henri Mon-
in order to maintain blinding of the investigators to study dor Hospital, Crteil, E. Maury, Saint-Antoine Hospital, Paris;
goals and minimize bias during the practice survey. How- M. Jourdain, R. Salengro Hospital, Lille; P. Beuret Roanne Hospital;
ever, this characteristic likely jeopardized the motivation ofS. Moulront, Dunkerque Hospital; N. Milesi-Defrance, General
Hospital, Dijon; I. Coquet and J.P. Quenot, Bocage Hospital,
ICU physicians to record data for the study, and it would Dijon; E. Boulet R. Dubos Hospital, Pontoise; L. Holzapfel
provide no protection against the tendency for only highly Fleyriat Hospital, Bourg en Bresse; D. Annane, Raymond Poincar
motivated centers to engage in such a study. The results Hospital, Garches; S. Jamali, Dourdan Hospital; H. Mentec, Victor
of this study cannot be extrapolated to all ICUs in France, Dupouy Hospital, Argenteuil; M. Monchi, J. Cartier Institut, Massy
Palaiseau; D. Goldran-Toledano, Sainte Justine Hospital, Gonesse;
and particularly in Switzerland, Belgium, or Canada where P. Vignon, Dupuytren Hospital, Limoges; M. Fartoukh, Tenon
there were only one or two participating centers. Hospital, Paris; J.C. Farkas, Saint Andr Polyclinic; J.P. Rigaud,
This study is in line with efforts at European level to Dieppe Hospital; J.L. Ricome Poissy Hospital, St Germain en
evaluate professional practices, and quantify the differ- Laye; C. Broux, Michalon Hospital, Grenoble; A. Mercat, Angers
Hospital; J. Boh Lyon Sud Hospital; P.E. Bollaert, Central Hospital,
ences between what is recommended in clinical guidelines Nancy; D. Villers, Hotel Dieu Hospital, Nantes; A. Combes, Piti
and/or the medical literature, and what actually happens in Salptrire Hospital, Paris; B. Raynard, G. Roussy Institut, Villejuif;
daily routine practice at the bedside. Lastly, no subgroup D. Dubois, Arras Hospital; J.F. Loriferne, St. Camille Hospital, Bry
analyses were possible (e.g., academic vs. nonacademic sur Marne; Richard C. Bictre Hospital; I. Mohammedi, E. Herriot
hospitals) in view of the low number of participating Hospital, Lyon; T. Boulain, Orlans Hospital; P. Tourneux, Amiens
Hospital; A. Lepape, Lyon Sud Hospital, Lyon, Switzerland:
centers. C. Vannay-Boubiche, Lausanne Hospital; F. Feihl, Lausanne
Hospital; MD Schaller Lausanne Hospital Canada: P. Jouvet, Sainte
Justine Hospital, Montreal, Quebec. Belgium: V. Fraipont, Citadelle
Hospital, Liege; C. Mlot, Erasm Hospital, Brussels. The TECLA
Conclusion Study Group is indebted to the Socit de Ranimation de Langue
The rate of use of standard medical therapies at the bedside Franaise, the company SCDMI (www.scdmi.com) and to the
Polytechnic School of the Free University of Brussels. We gratefully
in the setting of intensive care appears satisfactory, as far thank all the participating members of the study. We thank Fiona
as tidal volume in ARDS is concerned. Blood transfusion Ecarnot for editorial assistance.
1400
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