The epidemiology of septic shock in French intensive care units: the prospective multicenter cohort EPISS study
Quenot et al. Critical Care
The epidemiology of septic shock in French intensive care units: the prospective multicenter cohort EPISS study
Jean-Pierre Quenot 0 1
Christine Binquet 1
Fady Kara 1
Olivier Martinet 1
Frederique Ganster 1
Jean-Christophe Navellou 1
Vincent Castelain 1
Damien Barraud 1
Joel Cousson 1
Guillaume Louis 1
Pierre Perez 1
Khaldoun Kuteifan 1
Alain Noirot 1
Julio Badie 1
Chaouki Mezher 1
Henry Lessire 1
Arnaud Pavon 0 1
0 Service de reanimation medicale, Centre Hospitalier Universitaire Dijon , 14 rue Paul Gaffarel, 21970 Dijon , France
1 Hospitalier , Colmar , France; C Mezher, Centre Hospitalier , Montbeliard, France; J Cousson, T Floch, Hopital Robert Debre, Reims , France; G Louis, JF Poussel , Centre Hospitalier , Metz , France
Introduction: To provide up-to-date information on the prognostic factors associated with 28-day mortality in a cohort of septic shock patients in intensive care units (ICUs). Methods: Prospective, multicenter, observational cohort study in ICUs from 14 French general (non-academic) and university teaching hospitals. All consecutive patients with septic shock admitted between November 2009 and March 2011 were eligible for inclusion. We prospectively recorded data regarding patient characteristics, infection, severity of illness, life support therapy, and discharge. Results: Among 10,941 patients admitted to participating ICUs between October 2009 and September 2011, 1,495 (13.7%) patients presented inclusion criteria for septic shock and were included. Invasive mechanical ventilation was needed in 83.9% (n = 1248), inotropes in 27.7% (n = 412), continuous renal replacement therapy in 32.5% (n = 484), and hemodialysis in 19.6% (n = 291). Mortality at 28 days was 42% (n = 625). Variables associated with time to mortality, right-censored at day 28: age (for each additional 10 years) (hazard ratio (HR) = 1.29; 95% confidence interval (CI): 1.20-1.38), immunosuppression (HR = 1.63; 95%CI: 1.37-1.96), Knaus class C/D score versus class A/B score (HR = 1.36; 95%CI:1.14-1.62) and Sepsis-related Organ Failure Assessment (SOFA) score (HR = 1.24 for each additional point; 95%CI: 1.21-1.27). Patients with septic shock and renal/urinary tract infection had a significantly longer time to mortality (HR = 0.56; 95%CI: 0.42-0.75). Conclusion: Our observational data of consecutive patients from real-life practice confirm that septic shock is common and carries high mortality in general ICU populations. Our results are in contrast with the clinical trial setting, and could be useful for healthcare planning and clinical study design.
In recent years, our knowledge of the characteristics of
patients who are admitted to critical care with sepsis,
severe sepsis, or septic shock has greatly advanced
thanks to the findings of numerous observational studies
[1-6]. There is wide variation in the incidence of sepsis
and severe sepsis in the intensive care unit (ICU)
setting, with reported rates ranging from 20% to 80%, and
reported mortality of 20% to 50% [1-6]. Septic shock,
defined as a state of acute circulatory failure
characterized by persistent hypotension unexplained by other
causes, despite adequate fluid resuscitation , affects
between 10% and 30% of patients managed in the ICU
[1,3,4,8-10], and its incidence is increasing . Mortality
from septic shock in the ICU is estimated to range
between 45% and 63% in observational studies , but
is reportedly declining over time . These differences
between reports are largely related to the definitions
used to define infection [4,9,11], the different phases of
sepsis [7,12], and organ dysfunction [10,13,14].
In recent decades, several epidemiological studies have
been published focusing on sepsis and reporting data
from ICUs in France (either partially or entirely) [4,8,
11,15-17]. The only French study to date to have included
exclusively patients with septic shock was published by
Annane et al.  almost 10 years ago, with data collected
between 1993 and 2000. The authors of all these studies
have themselves acknowledged their limitations, which
include: short inclusion periods [4,8,11,15,16] that
preclude any evaluation of the impact of seasons; the
heterogeneity of the patients included [4,8,11,16,18]; short
follow-up (for example, 2 weeks) ; and use of a
database using ICD definitions, with the inherent risk of
wrong diagnostic codes, particularly since the codes were
not standardized . Despite these limiting factors, the
data from French ICUs is sufficiently robust to allow
comparison with data from other countries. The overall
frequency of septic shock was 8.2 per 100 admissions (in
2000), and crude mortality in the ICU was 60.1%,
declining from 62.1% in 1993 to 55.9% in 2000 .
However, all these French observational studies were
performed and reported before the publication of the
Surviving Sepsis Campaign [7,19], and before the
publication of French national guidelines for the management
of sepsis published jointly by the two French scientific
societies in critical care (Socit de Ranimation de
Langue Franaise (French-language society of intensive care,
SRLF, and Socit Franaise dAnesthsie Ranimation)
in 2006 [20,21]. Reports from other countries suggest
that compliance with these guidelines can have a
positive impact on mortality [22,23].
The objective of this study was to collect up-to-date
epidemiological data from real-life practice in France on
septic shock, to describe the survival probabilities at 3, 7,
and 28 days after an initial episode of septic shock and to
identify prognostic factors from these recent data.
This prospective cohort included all consecutive adult
patients with a diagnosis of septic shock admitted to 14
ICUs in 10 public hospitals (5 academic teaching hospitals
and 5 non-academic general hospitals) in the North-East
of France, between October 2009 and September 2011.
There were no specific non-inclusion criteria. Septic shock
was defined based on the PROWESS-SHOCK study ,
namely documented or suspected infection requiring
initiation of vasopressors despite adequate vascular filling,
with at least one of the following hypoperfusion criteria:
(1) metabolic acidosis (base excess 5 mEq/L, alkaline
reserve <18 mEq/L or lactate 2.5 mmol/L); (2) oliguria/
renal insufficiency (<0.5 mL/kg/h for 3 h or elevation
>50% of baseline creatinine); or (3) hepatic dysfunction
(AST or ALT >500 IU/L or bilirubin >34 mol/L). Unlike
in the PROWESS-SHOCK study, there was no minimum
requirement for vascular filling in our study.
Data collection included: socio-demographic
characteristics; chronic health status as evaluated by the Knaus
score; Simplified Acute Physiological Score (SAPS) II at
ICU admission ; SOFA score  over the 24 first h
following vasopressor initiation; infection site and germ(s),
when identified; life-support therapy in ICU and
in-hospital; length of ICU and hospital stay. We also
recorded immunosuppression, defined as presence of
cancer (solid tumors); hematological cancer; corticoid use (>3
weeks); transplantation; acquired immune deficiency
syndrome (AIDS); other (patients receiving chemotherapy;
cyclophosphamides; rituximab or other anti-organ
rejection agents). The Knaus Chronic Health Status score
consists of: Class A: normal health status, Class B: moderate
activity limitation, Class C: severe activity limitation due to
chronic disease, and Class D: bedridden patient .
Antimicrobial therapy was classified as appropriate if the
prescribed antimicrobial regimen was active against the
identified pathogen. Patients were followed up until 28
days after onset of shock (or until death if death occurred
first) and at hospital discharge. Patients with a second
episode of shock in-hospital or who were later re-admitted
for recurrent shock were not included a second time.
All data were collected using a standardized electronic
case report form by dedicated clinical research
assistants. Automatic checks were generated for missing or
incoherent data. According to French legislation,
patients (or their legal representative) were informed
that their data were collected for research purposes and
consent was obtained from the patient (or next of kin).
Collection of nominative data was approved by the
national authority for the protection of privacy and
personal data, and by the ethics committee of the French
Society of Intensive Care.
Quantitative variables are reported using mean (
standard deviation (SD)) or median (Interquartile range (IQR))
according to their distribution and qualitative variables as
number (percentage). The SAPS II and SOFA variables
were divided into two classes according to the median,
and age was divided into four categories for the estimation
of survival probabilities and log-rank comparison.
Follow-up was censored at 28 days. Survival probabilities
were estimated using the Kaplan-Meier product-limit
method at 3, 7, and 28 days and compared using the Log
rank test. At an alpha risk of 5%, a beta risk of 10%, and
an expected observed mortality rate of 50%, we calculated
that 1,400 patients would be necessary to ensure adequate
statistical power to detect a minimal relative risk of 1.25
[28-30]. Based on conservative estimates of inclusions in
participating centers, we hypothesized that a time window
of 24 months would be necessary to accrue an adequate
number of patients. Correlations between variables were
systematically estimated using Pearson or Spearmans rank
correlation, as appropriate. In case of colinearity (P > 0.6),
the most informative variable was selected for inclusion in
the model, based on clinical arguments and Akaike
information criterion . Multivariate analyses were
performed using a Cox proportional hazards model 
including previously selected factors associated with time
to mortality, right censored at day 28 with a P value < 0.25
in bivariate analyses. A backward selection procedure was
applied to identify factors significantly associated with
time to death (P 0.05). Proportionality was checked by
testing for a non-zero slope in a generalized linear
regression of the scaled Schoenfeld residuals on the natural
logarithm of time . The log-linearity of the relationship
between continuous variables and time to death was
checked using fractional polynomials . Inappropriate
antimicrobial therapy was considered as a time-varying
covariate. All analyses were stratified by center.
Analyses were performed using SAS version 9.2 (SAS
Institute, Cary, NC, USA) and Stata version 10.0.
Patients admitted to the ICUs of participating hospitals
were systematically screened between October 2009 and
September 2011. A total of 10,941 patients were admitted
to the participating ICUs during the study period. Among
these, 1,495 (13.7%) presented a septic shock and were
included in the study. Complete follow-up was obtained
for 1,488 patients (99.5%); seven were lost to follow-up.
The baseline characteristics and the survival probabilities
at 3, 7, and 28 days are shown in Table 1. Median age was
68 years (range, 58-78 years), almost two-thirds were men.
The majority of admissions were of medical origin (84%).
The most common co-morbidities were immune
deficiency in 31% (n = 456), and 23% of patients had least two
co-morbidities. The median (IQR) SAPS II and SOFA
scores were 56 [45-70] and 11 [9-14], respectively.
Approximately two-thirds of patients presented
community-acquired infection, and more than half had respiratory
tract infection (53.6%) as the primary site of infection at
the origin of septic shock. The infectious organism was
identified in 1,035 (69.5%) patients who presented septic
shock, and an antibiogram was available in 967 of these
patients (93%). Gram-negative bacilli were the most
frequent pathogens in 48.7%, while Gram-positive cocci
micro-organisms were identified in 35.9% (Table 2).
Appropriate antimicrobial therapy, given in 898 patients;
was initiated mainly before, or at the same time as septic
shock (n = 493/860 with known time to treatment
initiation), or within the 3 days following shock (n = 338/860).
Only 69/967 (7%) patients had inappropriate antibiotic
Outcomes and interventions
In total, 625/1488 (42%) died within the 28 days following
the septic shock. ICU and in-hospital mortality rates were
39.5% and 48.7%, respectively. Patient outcomes are
described in Table 3. Life-support therapy during hospital
stay is described in Table 4. Invasive mechanical
ventilation was required in most patients (83.9%) at the start of
septic shock. Continuous renal replacement therapy and
intermittent hemodialysis were used in 32.5% and 19.6%,
The factors found to be significantly associated with a
shorter time to death, right censored at day 28, are
shown in Table 5. Patients with urinary tract infection
as the origin of septic shock had a significantly longer
time to death (Table 5).
To avoid colinearity between SAPS II and SOFA
scores (P = 0.65), only SOFA score was included in the
model. The origin of patients and the reason for
admission were not included in the model. Factors identified
by multivariate Cox analysis as significantly associated
with time to death, right censored at 28 days were: age,
immunosuppression, SOFA score, and Knaus C/D score
(Table 5). Urinary tract infection had a significant
protective effect. The hypothesis of log-linearity could not
be rejected for age (P = 0.287) and SOFA score (P =
0.767). Conversely, SOFA score was shown to have a
time-dependent effect (P < 10-4), with the effect
decreasing over time. Inappropriate antibiotic therapy was not
found to be associated with time to mortality right
censored at day 28 (P = 0.897) (after adjusting for other
covariates and for the interaction between SOFA score
and the natural logarithm of time).
In this large-scale, multicenter study of septic shock in
French ICUs, we observed an incidence of 13.5%, and
death rates of 39.5%, 42%, and 48.7% at ICU discharge,
28 days, and hospital discharge, respectively. Our
findings represent the most recent data on incidence and
mortality of septic shock from France, using a
standardized definition of septic shock  combined with
hypoperfusion criteria, as defined in the
PROWESSSHOCK study . Over the period 1993 to 2000, the
overall incidence of septic shock in France was reported
to be on average 8.2 per 100 admissions , with the
authors reporting an increase over the period from 7.0
in 1993 to 9.7 per 100 admissions in 2000. Mean
mortality over the same period was 60.1%, with a decreasing
trend from 62.1% in 1993 to 55.9% in 2000. The
increasing incidence and high mortality observed by Annane et
al. was partially explained by the increasing age of
patients admitted to the ICU over the period under
P value (log-rank test)
Chronic respiratory failurec
AIDS, acquired immune deficiency syndrome; BMI, body mass index; N/A, not available; NYHA, New York Heart Association.
aAccording to the Kaplan Meier product-limit method.
bPatients could have more than one comorbidity and/or site of infection.
cOne missing datum.
Two missing data.
study, with ever more co-morbidities, particularly
Recent studies from various countries around the world
have reported mortality rates from 35% to 59% (in-hospital
or at 30 days) [5,6,8,18,36], albeit with study populations
that were more heterogeneous than that included in our
study. Our results are especially important in that they
were prospectively collected in a broad mix of ICUs in a
contemporary period over 18 months, after the publication
of several major trials related to treatment of sepsis likely
to have influenced management [37-39]. In these recent
interventional studies, the hospital mortality rates reported
in the control group ranged from 46.5% to 69% and from
30.5% to 60% in the treatment groups [37,39]. The 28-day
mortality was also different in these recent interventional
studies, reportedly ranging from 24% to 61% in the control
group, and from 24.7% to 55% in the treatment group.
The difference was explained by the inclusion and
exclusion criteria, and the severity at inclusion, which may not
have accurately reflected real life patient populations.
In recent years, several sets of guidelines have been
issued and updated on the management of sepsis in the
setting of intensive care [19,23]. In addition, national
guidelines have been issued in France jointly by the two
French scientific societies in critical care (Socit de
Ranimation de Langue Franaise (French-language
society of intensive care, SRLF, and Socit Franaise
dAnesthsie Ranimation) in 2006 [20,21]. The
implementation of these recommendations in practice has
favorably influenced patient prognosis, as reported in
several studies, particularly due to earlier recognition of
the severity of disease, followed by consistent,
multidisciplinary management [22,23,40,41]. Other authors
have reported a reduction in mortality in-hospital or at
Table 2 Germs responsible for infection in 1,035/1,488 septic shock patients in whom the causative microorganism
was identified (EPISS study - 2009 to 2011).
P value (log-rank test)
aAccording to the Kaplan-Meier product-limit method
All (n = 1,035)
Table 3 Outcomes at ICU discharge, at 28 days, and
hospital discharge after septic shock in the study
population of 1,488 patients (EPISS study - 2009 to 2011).
ICU mortality, n (%)
Median (IQR) length of ICU stay, days
28-day mortality, n (%)
In-hospital mortality, n (%)
Median (IQR) length of hospital stay, days
ICU, intensive care unit; IQR, interquartile range.
All (n = 1,488)
28 days, after the rigorous implementation of such
guidelines [41,42]. Our data show that mortality in the ICU
decreased by approximately 17% between 2000  and
the period 2009 to 2011 (inclusion period of our study),
for patients with septic shock and comparable severity at
admission (mean SAPS II score of 56 in the study by
Annane et al. vs. 58 in our study). These data suggest
that management has improved over the last decade, and
undoubtedly, the publication of international clinical
practice guidelines for management contributed to this
trend, although a recent study by Leone et al. showed
that there is still room for considerable improvement
before guidelines are fully implemented .
Conversely, overall hospital mortality only decreased by
around 10% over the same period, after initial ICU stays of
15.2 days on average in the report by Annane et al. 
versus 9 days in our study. This suggests that despite
earlier recognition and management, with likely more
appropriate therapy, the effectiveness of post-ICU care of septic
shock patients remains suboptimal . It is possible that
certain patients expressed their desire not to be
resuscitated or re-admitted to ICU, or that a decision to limit or
withdraw therapy may have been made by physicians.
Such factors could also explain the reduced mortality
benefit that we observed during the ICU stay. Padkin et al.
Table 4 Life-support therapy during hospital stay in the
study population of 1,488 patients with septic shock
(EPISS study - 2009 to 2011).
IQR, interquartile range; N/A, not available.
reported post-ICU mortality of 12.3%, corresponding to
18% of patients discharged alive from the ICU but who
subsequently died before being discharged from the
hospital . Inappropriately early discharge  or discharge
to an unsuitable follow-up ward because of excessive
workload could also be contributing factors [45,46].
The independent prognostic factors for time to
mortality right censored at day 28 identified in our study were
age, immunosuppression, SOFA score, and Knaus score
C/D. Conversely, we observed that urinary tract infection
as the origin of sepsis had a protective effect. In a similar
population, Annane et al. showed that age, severity of
illness, characteristics of infection, and life-support therapy
were associated with ICU mortality . However, in our
study, life-support therapy was not included in the
multivariate analysis, as it is a time-dependent variable with no
adjustment for the updated SOFA value, and this could
introduce an indication bias. The prognostic factors for
death in septic shock patients reported in the literature
vary widely according to the type of statistical analysis
(uni- or multivariate), the primary endpoint (28-day,
ICU, or in-hospital mortality), and the inclusion criteria
of the studies.
The rate of documented infection varies from 52% to
90% in the literature, while in our study infection with an
identified microorganism was documented in nearly 60%
of septic shock cases. As regards the site of infection
responsible for septic shock, the most common locations
were pulmonary (48.5%), abdominal (17.6%), and urinary
tract (9.5%), as reported in previous studies [3,6,8,16,47].
Our results show that gram-negative organisms currently
account for a majority of infections, as reported in other
studies [6,8,16]. However, in our study, we did not observe
the germ responsible for infection to be associated with
28-day mortality. This corroborates findings from another
recent French study that included over 4,000 episodes of
severe sepsis in 3,588 patients .
Early appropriate antibiotic therapy is of capital
importance in the management of sepsis, as reported by several
authors [40,49]. In our study, all patients in whom the
causative microorganism was identified by antibiogram were
classified according to whether they received appropriate
antimicrobial therapy or not. However, it is noteworthy
that in our study, antibiotic therapy (appropriate or
inappropriate) was not shown to be significantly associated
with time to death, right censored at 28 days, which
reflects findings by other authors . It is more probable
that the severity, mirrored by the level of organ
dysfunction at the time of the shock, and expressed by the SOFA
score, is a major determinant of mortality in septic shock
patients. Therefore, an organ dysfunction score should be
measured at inclusion in sepsis studies, as it can be used
for stratification of patients and for adjustment when
assessing outcome . In addition to these variables,
Type of admission (surgery vs. medical)
Origin (transfer vs. home/nursing home)
Table 5 Factors associated with time to mortality, right censored at 28 days, by the Cox model in the study
population of 1,488 patients with septic shock (EPISS study - 2009 to 2011).
Univariate Cox models
Full Cox model
Final Cox model
BMI, body mass index; CI, confidence interval; HR, hazard ratio; NYHA, New York Heart Association; SOFA, Sepsis-related Organ Failure Assessment.
others factors not measured in our study may also
influence outcome in patients with septic shock and thus help
refine prognostic prediction. For example, cytokine levels
or other markers of inflammation may have a role to play,
as suggested by a recent expert panel .
This study has several strengths. Diagnosis of septic
shock was prospective and used standard criteria similar
to those used in most clinical trials in this clinical setting.
The sites included both university teaching hospitals and
general (non-academic) hospitals of various sizes. Accrual
was over a relatively long but contemporary time period,
with prospective inclusion of all consecutive patients and
practically no loss to follow-up. The population was
homogeneous, comprising only patients with septic shock,
and not a mix of sepsis, severe sepsis, and septic shock as
in many published studies. The large sample size yields
narrow confidence intervals around the estimates of
mortality and made it possible to include a considerable
number of variables in the regression analysis. Participating
sites entered study data directly into a specially designed
software programme, and data were of a high standard
thanks to extensive data checking at the time of data entry
by the clinical research assistants. Similarly, data were
monitored, verified, and analyzed by a highly-qualified,
central coordinating center (INSERM CIE 1).
Conversely, a few limitations of this study deserve to be
underlined, and include the lack of detailed
pre-ICUadmission data (for example, fluid challenge, exact time of
onset of signs of sepsis). The majority of known prognostic
factors were included in our analysis, but we cannot
exclude that other variables not recorded in our study (for
example, biomarkers) may have influenced outcome. Since
selection of the investigating sites was on a voluntary
basis, there is a possibility that only the most motivated
centers participated, and results should not be
extrapolated to other contexts. Furthermore, the fact that several
participating sites were also participating in the
ProwessShock study may have influenced prescriptions of
drotrecogin alpha in our study. Lastly, the population of this
study is mainly composed of medical patients (almost
84%) and therefore, results cannot be extrapolated to the
entire population of ICU patients in France.
In summary, our results show that a large-scale cohort
of septic shock patients is feasible using simplified
computer-based data collection, and shows that mortality
among this patient group is still very high. This can be
explained by the fact that patients with septic shock
admitted to the ICU are generally older, with more
comorbidities, a worse previous state of health, and requiring
more life-support therapies. These observations may be
useful for quality improvement of the care provided to
patients at risk of, or with confirmed septic shock, for the
design of future clinical studies and for healthcare
This is the first large-scale epidemiological study
performed in France since the publication of the Surviving
Sepsis Campaign recommendations and of French
national guidelines for the management of septic
Mortality in the ICU among patients admitted for
septic shock is declining, or rather, death occurs at a
later stage. In-hospital mortality has remained constant
for many years, likely due to better initial management.
The older age, greater dependency, and more
frequent co-morbidities among ICU patients admitted for
septic shock probably also explain why overall
mortality has remained stable over time.
Mortality at 28 days after an initial episode of septic
shock in the ICU was 42% in this prospective,
multicenter, cohort study from 14 ICUs in 10 public
hospitals in France. Main factors significantly associated
with time to death, right censored at 28 days were age,
Knaus, and SOFA scores.
ICU: Intensive Care Unit; IQR: interquartile range; SAPS II: Simplified Acute
Physiological Score II; SD: standard deviation; SOFA: Sepsis-related Organ
The authors declare that they have no competing interests.
Study conception and design: JPQ, CB, AP; Data acquisition: All authors;
Study coordination: VC, JC, GL, PP, AN; Statistical analysis: JPQ, CB, AP;
Drafting of the manuscript: JPQ, CB, AP, FG, JCN; Critical revision of the
manuscript: All; Final approval of the manuscript for submission: All.
The authors thank Fiona Ecarnot for translation and editorial assistance and
Amel Mahboubi for help with the statistical analysis.
The investigators of the EPISS study group are listed below:
JP Quenot, PE Charles, S Prin, A Pavon, S Barbar, University Hospital Bocage,
Dijon, France; K Kuteifan, J Mootien, P Guiot, Centre Hospitalier, Mulhouse,
France; F Kara, Centre Hospitalier, Haguenau, France; M Hasselmann, P
Sauder, F Ganster, O Martinet, Nouvel Hopital Civil, Strasbourg, France; V
Castellain, F Schneider, Hopital Hautepierre, Strasbourg, France; JC Navellou,
G Capellier, Centre Hospitalier Universitaire, Besancon, France; A Noirot, P
Daoudal, Centre Hospitalier, Vesoul, France; O Ruyer, M Feissel, JP Faller,
Centre Hospitalier, Belfort, France; B Levy, A Gerard, J Perny, P Perez, Hopital
Brabois, Nancy, France; S Gibot, PE Bollaert, D Barraud, A Cravoisy, Hopital
Central, Nancy, France; AM Gutbub, P Rerat, G Laplatte, H Lessire, Centre
1Service de ranimation mdicale, Centre Hospitalier Universitaire Dijon, 14
rue Paul Gaffarel, 21970 Dijon, France. 2Centre dinvestigation clinique
(INSERM CIE 1), 7 Boulevard Jeanne dArc, 21079 Dijon, France. 3Service de
ranimation polyvalente, Centre Hospitalier, 64 avenue du Professeur Leriche,
67504 Haguenau, France. 4Service de ranimation Mdicale, Centre
Hospitalier Universitaire-Nouvel Hpital Civil, 1 Place de lHopital, 67000
Strasbourg, France. 5Service de ranimation mdicale, Centre Hospitalier
Universitaire Jean-Minjoz, 8 Boulevard Fleming, 25000 Besanon, France.
6Service de ranimation mdicale, Centre Hospitalier Universitaire- Hpital
Hautepierre, 1 Avenue Moliere, 67098 Strasbourg, France. 7Service de
ranimation mdicale, Centre Hospitalier Universitaire- Hpital Central, 29
Avenue du Marchal de Lattre de Tassigny, 54000 Nancy, France. 8Service de
ranimation mdicale, Centre Hospitalier Universitaire, 45 Rue Cognacq Jay,
51092 Reims, France. 9Service de ranimation polyvalente, Centre Hospitalier,
1 Place Sainte-Croix, 57000 Metz, France. 10Service de ranimation mdicale,
Centre Hospitalier Universitaire- Hpital Brabois, 5 Rue du Morvan, 54500
Vandoeuvre-ls-Nancy, France. 11Service de ranimation mdicale, Centre
Hospitalier, 2A Rue Jura, 68100 Mulhouse, France. 12Service de ranimation
mdicale, Centre Hospitalier, 2 Rue Ren Heymes, 70000 Vesoul, France.
13Service de ranimation polyvalente, Centre Hospitalier, 14, rue de
Mulhouse, 90016 Belfort, France. 14Service de ranimation polyvalente,
Centre Hospitalier, 2 rue du Docteur Flamand, 25200 Montbliard, France.
15Service de ranimation polyvalente, Centre Hospitalier, 39 Avenue de la
Libert, 68000 Colmar, France Presented in part the at the 31st International
Symposium on Intensive Care and Emergency Medicine.
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