Au cours de l’administration simultanée de plusieurs médicaments injectables, sont utilisées une ligne principale de perfusion et une ou plusieurs ligne(s) en dérivation. La ligne principale est directement reliée au cathéter et permet l’administration des solutions utilisées pour l’apport hydro-électrolytique ou de maintenir une voie d’abord veineuse perméable. Les autres thérapeutiques vont être perfusées en dérivation de cette ligne principale. La prise en charge des patients relevant de soins intensifs et de réanimation nécessite une polymédication. Les traitements d’urgence impliquent majoritairement des médicaments à marge thérapeutique étroite. Lors de l’administration de médicaments en solutions concentrées, de faibles perturbations du débit d’administration peuvent engendrer de fortes perturbations cliniques et notamment, pour les médicaments vasoactifs, créer une instabilité hémodynamique. C’est pourquoi il est important d’étudier la problématique de la perfusion simultanée, de déterminer l’impact sur le débit massique des lignes de perfusion et la technique optimale des changements de seringues pour prévenir les variations intempestives du débit de perfusion. Ce mémoire présente un travail de développement et d’évaluation d’une démarche d’optimisation d’un système de perfusion complexe. Il consiste à étudier au travers d’évaluations in vitro et d’études cliniques la conception d’une ligne de perfusion en évaluant notamment un dispositif médical innovant afin de proposer, in fine, une solution applicable dans un service de soins intensifs. La première partie consiste à présenter l’ensemble des dispositifs médicaux de perfusion utilisés dans un département d’anesthésie-réanimation. La seconde partie s’intéresse à l’administration d’un médicament couramment perfusé sur la voie proximale: la noradrénaline. Les études in vitro, corroborées par des données cliniques, ont permis de montrer la supériorité de l’administration de noradrénaline à 0,5 mg/mL perfusée en Y avec une solution saline isotonique à débit fixe de 5 mL/h. Cette multiperfusion fait intervenir l’utilisation d’un prolongateur trois voies à faible volume résiduel, permettant d’optimiser les conditions de relais de seringues, connues comme étant à l’origine d’instabilités hémodynamiques chez les patients traités par catécholamines. Un programme hospitalier de recherche clinique interrégional est déposé dans le but d’établir des recommandations de perfusion des catécholamines.La troisième partie aborde l’administration des médicaments sur voie distale en sélectionnant l’insuline comme marqueur-médicament. Les résultats de cette étude clinique prospective randomisée contrôlée ont montré que l’utilisation d’un dispositif médical innovant, le dispositif Edelvaiss-Multiline 8 (Doran International) caractérisé par un tube multilumières à faible volume résiduel qui permet de dédier une voie à une seule thérapeutique, permettait de réduire significativement le temps passé en hypoglycémie pour 1000 heures de perfusion d’insuline au cours de perfusion continue d’insuline en soins intensifs périopératoires.Enfin, dans une dernière partie, les critères clés d’un montage optimisé de multiperfusion sont élaborés et sont mis en application dans un département d’anesthésie-réanimation dans le but d’optimiser et uniformiser la ligne de perfusion des patients. Ce travail a permis de valider les caractéristiques clés de la ligne de perfusion définis dans de précédentes études non cliniques : la nature du matériau des dispositifs médicaux utilisés, l’utilisation de valves appropriées, la minimisation des volumes internes des tubulures de perfusion, l’utilisation de systèmes de perfusion automatisés permettant de contrôler au mieux le débit d’administration des médicaments. / For the simultaneous administration of injectable drugs, the infusion line includes a main line with one or several derivative lines. The main line, which is directly connected to the catheter, is dedicated to hydration infusion or to maintain a permeable vein. Other medications will be added on the derivative lines.Intensive care unit patients frequently require lots of medications in the same time. Most of emergency drugs are substances with narrow therapeutic range. When concentrated solutions are employed, tiny mass flow rate disturbances can provoke clinical damages, such as haemodynamic instability. So, several parameters have been studied on simultaneous infusions: mass flow rate and syringes changeovers.The purpose of this work was to develop and optimize complex infusion line systems. An innovative infusion medical device has been evaluated in clinical trials and in vitro studies. The final objective was to design an optimized infusion line, which could be applied to ICUs.The whole medical devices used in ICUs was first listed. Then, noradrenaline has been used as the reference drug to study central venous catheter proximal line. A 0.5 mg/mL noradrenaline solution Y-infused with a saline (5mL/h) has been shown by clinical and in vitro data to be the best solution. Nevertheless, this conclusion was valid only with the use of a very low dead-space volume Y-extension set. Thanks to this device, syringe changeovers optimization is possible.The central venous catheter distal line has been studied in a second time through an open randomized controlled prospective clinical trial. Primary endpoint of the study was the impact of two different insulin infusion lines (Edelvaiss-Multiline 8, Doran International versus standard line) on glycaemic variability. Doran’s innovative device consists of an exten¬sion set with eight accesses connected to nine separated lumens in a single tube. This allows to dedicate an isolated way for insulin. With its use, a significant decrease of hypoglycaemia occurring in 1000h of infusion period was clinically demonstrated. Finally, all the data were synthetized to optimize an ICU multi-infusion line. The one, which has been designed for surgery and intensive care units, was tested on patients.To conclude, items responsible for mass flow rate disturbances have been identified: medical devices material, addition of appropriated valves, internal volume line minimization and use of automated infusion systems (as pumps). The ideal infusion line has to take into account all these parameters.

The aim of this thesis is to contribute to the clarification of the pathogenesis of chronic complications of diabetes mellitus. The main goal of the research was glycaemic variability, its contribution to the activation of oxidative stress and its possible role in the process of advanced glycation, all beyond the scope of persistent hyperglycaemia itself. Another aim of the work is to contribute to the clarification of a possible relationship between glycaemic variability and vascular complications of diabetes. We were the first to describe the association between the concentrations of reactive aldehydes formed during lipid peroxidation and disorders of skin microvascular reactivity in patients with type 1 diabetes (DM1). Elevated markers of oxidative stress were found in this group, furthermore during the 3 years of follow-up higher plasma antioxidant activity was observed. These findings were not dependent of the method of glucose monitoring and glucose variability, which was lower in a subgroup of patients using real-time continuous glucose monitoring (rt-CGM), compared to a subgroup using conventional glucometers. However, it is clear, that hyperglycaemia alone induces increased oxidative stress in patients with diabetes. Simultaneously we observed the opposite process of oxidative stress...

The analysis of non steady state physiological and pathological processes concerns the abstraction, extraction, formalisation and analysis of information from physiological systems that is obscured, hidden or unable to be assessed using traditional methods. Time Series Analysis (TSA) techniques were developed and built into a software program, Easy TSA, with the aim of examining the oscillations of hormonal concentrations in respect to their temporal aspects – periodicity, phase, pulsatility. The Easy TSA program was validated using constructed data sets and used in a clinical study to examine the relationship between insulin and obesity in people without diabetes. In this study fifty-six non-diabetic subjects (28M, 28F) were examined using data from a number of protocols. Fourier Transform and Autocorrelation techniques determined that there was a critical effect of the level of BMI on the frequency, amplitude and regularity of insulin oscillations. Second, information systems formed the background to the development of an algorithm to examine glycaemic variability and a new methodology termed the Glycaemic Risk in Diabetes Equation (GRADE) was developed. The aim was to report an integrated glycaemic risk score from glucose profiles that would complement summary measures of glycaemia, such as the HbA1c. GRADE was applied retrospectively to blood glucose data sets to determine if it was clinically relevant. Subjects with type 1 and type 2 diabetes had higher GRADE scores than the non-diabetic population and the contribution of hypo- and hyperglycaemic episodes to risk was demonstrated. A prospective study was then designed with the aim to apply GRADE in a clinical context and to measure the statistical reproducibility of using GRADE. Fifty-three (Male 26, Female 27) subjects measured their blood glucose 4 times daily for twenty-one days. The results were that lower HbA1c’s correlated with an increased risk of hypoglycaemia and higher HbA1c’s correlated with an increased risk of hyperglycaemia. Some subjects had HbA1c of 7.0 but had median GRADE values ranging from 2.2 to 10.5. The GRADE score summarized diverse glycaemic profiles into a single assessment of risk. Well-controlled glucose profiles yielded GRADE scores <= 5 and higher GRADE scores represented increased clinical risk from hypo or hyperglycaemia. Third, an information system was developed to analyse data-rich multi-variable retinal images using the concept of assessment of change rather than specific lesion recognition. A fully Automated Retinal Image Differencing (ARID) computer system was developed to highlight change between retinal images over time. ARID was validated using a study and then a retrospective study sought to determine if the use of the ARID software was an aid to the retinal screener. One hundred and sixty images (80 image pairs) were obtained from Gloucestershire Diabetic Eye Screening Programme. Images pairs were graded manually and categorised according to how each type of lesion had progressed, regressed, or not changed between image A and image B. After a 30 day washout period image pairs were graded using ARID and the results compared. The comparison of manual grading to grading using ARID (Table 4.3) demonstrated an increased sensitivity and specificity. The mean sensitivity of ARID (87.9%) was increased significantly in comparison to manually grading sensitivity (84.1%) (p<0.05). The specificity of the automated analysis (87.5%) increased significantly from the specificity (56.3%) achieved by manually grading (p<0.05). The conclusion was that automatic display of an ARID differenced image where sequential photographs are available would allow rapid assessment and appropriate triage. Forth, non-linear dynamic systems analysis methods were utilised to build a system to assess the extent of chaos characteristics within the insulin-glucose feedback domain. Biological systems exist that are deterministic yet are neither predictable nor repeatable. Instead they exhibit chaos, where a small change in the initial conditions produces a wholly different outcome. The glucose regulatory system is a dynamic system that maintains glucose homeostasis through the feedback mechanism of glucose, insulin, and contributory hormones and was ideally suited to chaos analysis. To investigate this system a new algorithm was created to assess the Normalised Area of Attraction (NAA). The NAA was calculated by defining an oval using the 95% CI of glucose & Insulin (the limit cycle) on a phasic plot. Thirty non-diabetic subjects and four subjects with type 2 diabetes were analysed. The NAA indicated a smaller range for glucose and insulin excursions with the non-diabetics subjects (p<0.05). The conclusion was that the evaluation of glucose metabolism in terms of homeostatic integrity and not in term of cut-off values may enable a more realistic approach to the effective treatment and prevention of diabetes and its complications.