Adrien Bouglé

Is Epinephrine During Cardiac Arrest Associated With Worse Outcomes in Resuscitated Patients

BACKGROUND Although epinephrine is essential for successful return of spontaneous circulation (ROSC), the influence of this drug on recovery during the post-cardiac arrest phase is debatable. OBJECTIVES This study sought to investigate the relationship between pre-hospital use of epinephrine and functional survival among patients with out-of-hospital cardiac arrest (OHCA) who achieved successful ROSC. METHODS We included all patients with OHCA who achieved successful ROSC admitted to a cardiac arrest center from January 2000 to August 2012. Use of epinephrine was coded as yes/no and by dose (none, 1 mg, 2 to 5 mg, >5 mg). A favorable discharge outcome was coded using a Cerebral Performance Category 1 or 2. Analyses incorporated multivariable logistic regression, propensity scoring, and matching methods. RESULTS Of the 1,556 eligible patients, 1,134 (73%) received epinephrine; 194 (17%) of these patients had a good outcome versus 255 of 422 patients (63%) in the nontreated group (p < 0.001). This adverse association of epinephrine was observed regardless of length of resuscitation or in-hospital interventions performed. Compared with patients who did not receive epinephrine, the adjusted odds ratio of intact survival was 0.48 (95% confidence interval [CI]: 0.27 to 0.84) for 1 mg of epinephrine, 0.30 (95% CI: 0.20 to 0.47) for 2 to 5 mg of epinephrine, and 0.23 (95% CI: 0.14 to 0.37) for >5 mg of epinephrine. Delayed administration of epinephrine was associated with worse outcome. CONCLUSIONS In this large cohort of patients who achieved ROSC, pre-hospital use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite post-resuscitation interventions. These findings suggest that additional studies to determine if and how epinephrine may provide long-term functional survival benefit are needed.

Epidemiology and outcome of severe pneumococcal pneumonia admitted to intensive care unit: a multicenter study

IntroductionCommunity-acquired pneumonia (CAP) account for a high proportion of ICU admissions, with Streptococcus pneumoniae being the main pathogen responsible for these infections. However, little is known on the clinical features and outcomes of ICU patients with pneumococcal pneumonia. The aims of this study were to provide epidemiological data and to determine risk factors of mortality in patients admitted to ICU for severe S. pneumoniae CAP.MethodsWe performed a retrospective review of two prospectively-acquired multicentre ICU databases (2001-2008). Patients admitted for management of severe pneumococcal CAP were enrolled if they met the 2001 American Thoracic Society criteria for severe pneumonia, had life-threatening organ failure and had a positive microbiological sample for S. pneumoniae. Patients with bronchitis, aspiration pneumonia or with non-pulmonary pneumococcal infections were excluded.ResultsTwo hundred and twenty two patients were included, with a median SAPS II score reaching 47 [36-64]. Acute respiratory failure (n = 154) and septic shock (n = 54) were their most frequent causes of ICU admission. Septic shock occurred in 170 patients (77%) and mechanical ventilation was required in 186 patients (84%); renal replacement therapy was initiated in 70 patients (32%). Bacteraemia was diagnosed in 101 patients. The prevalence of S. pneumoniae strains with decreased susceptibility to penicillin was 39.7%. Although antibiotherapy was adequate in 92.3% of cases, hospital mortality reached 28.8%. In multivariate analysis, independent risk factors for mortality were age (OR 1.05 (95% CI: 1.02-1.08)), male sex (OR 2.83 (95% CI: 1.16-6.91)) and renal replacement therapy (OR 3.78 (95% CI: 1.71-8.36)). Co-morbidities, macrolide administration, concomitant bacteremia or penicillin susceptibility did not influence outcome.ConclusionsIn ICU, mortality of pneumococcal CAP remains high despite adequate antimicrobial treatment. Baseline demographic data and renal replacement therapy have a major impact on adverse outcome.

Is copeptin level associated with 1-year mortality after out-of-hospital cardiac arrest? Insights from the Paris registry*.

Objectives:The availability of circulating biomarkers that helps to identify early out-of-hospital cardiac arrest survivors who are at increased risk of long-term mortality remains challenging. Our aim was to prospectively study the association between copeptin and 1-year mortality in patients with out-of-hospital cardiac arrest admitted in a tertiary cardiac arrest center. Design:Retrospective monocenter study. Setting:Tertiary cardiac arrest center in Paris, France. Patients:Copeptin was assessed at admission and day 3. Pre- and intrahospital factors associated with 1-year mortality were analyzed by multivariate Cox proportional analysis. Interventions:None. Measurements and Main Results:Two hundred ninety-eight consecutive out-of-hospital cardiac arrest patients (70.3% male; median age, 60.2 yr [49.9–71.4]) were admitted in a tertiary cardiac arrest center in Paris (France). After multivariate analysis, higher admission copeptin was associated with 1-year mortality with a threshold effect (hazard ratio5th vs 1st quintile = 1.64; 95% CI, 1.05–2.58; p = 0.03). Day 3 copeptin was associated with 1-year mortality in a dose-dependent manner (hazard ratio2nd vs 1st quintile = 1.87; 95% CI, 1.00–3.49; p = 0.05; hazard ratio3rd vs 1st quintile = 1.92; 95% CI, 1.02–3.64; p = 0.04; hazard ratio4th vs 1st quintile = 2.12; 95% CI, 1.14–3.93; p = 0.02; and hazard ratio5th vs 1st quintile = 2.75; 95% CI, 1.47–5.15; p < 0.01; p for trend < 0.01). For both admission and day 3 copeptin, association with 1-year mortality existed for out-of-hospital cardiac arrest of cardiac origin only (p for interaction = 0.05 and < 0.01, respectively). When admission and day 3 copeptin were mutually adjusted, only day 3 copeptin remained associated with 1-year mortality in a dose-dependent manner (p for trend = 0.01). Conclusion:High levels of copeptin were associated with 1-year mortality independently from prehospital and intrahospital risk factors, especially in out-of-hospital cardiac arrest of cardiac origin. Day 3 copeptin was superior to admission copeptin: this could permit identification of out-of-hospital cardiac arrest survivors at increased risk of mortality and allow for close observation of such patients.

Short-Acting β-Blocker Administration in Patients With Septic Shock

Author Contributions: Drs Hanauer and Davis had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hanauer, Zheng, Singer, Davis. Acquisition of data: Hanauer, Singer, Gebremariam, Davis. Analysis and interpretation of data: Hanauer, Zheng, Gebremariam, Davis. Critical revision of the manuscript for important intellectual content: Hanauer, Zheng, Singer, Gebremariam, Davis. Statistical analysis: Gebremariam, Davis. Administrative, technical, and material support: Hanauer, Singer, Gebremariam. Study supervision: Hanauer, Zheng, Davis.

Prédisposition génétique et sepsis

Les maladies infectieuses representent la premiere cause de mortalite dans le monde. Malgre les importants progres realises dans la prise en charge des infections les plus graves, comme le sepsis severe et le choc septique, le pronostic reste sombre, avec une mortalite avoisinant 40–50 % chez les patients hospitalises en reanimation pour etat de choc septique. Cette constatation a permis de penser qu’outre les facteurs d’immunosuppression acquis (deficit immunitaire postinfectieux, infection par le virus de l’immunodeficience humaine, splenectomie, aplasie), des facteurs genetiques existent et peuvent predisposer l’individu a certaines pathologies infectieuses ou e des presentations inhabituellement graves d’infections « banales ». De plus, l’existence de recurrences familiales a ete un argument supplementaire pour suspecter la presence de variants genetiques pouvant expliquer les differences phenotypiques cliniques et biologiques observees quotidiennement. La suspicion d’un « facteur genetique » pouvant influencer le risque de developper une maladie infectieuse n’est pas un sujet « moderne ». En effet, des 1933, Webster rapportait dans le Journal of Experimental Medicine la selection de lignees de souris susceptibles ou resistantes a l’infection par Bacillus enteritidis, soulignant le role du fond genetique murin dans la reponse a l’agression microbienne [1, 2]. Il a cependant fallu attendre plusieurs dizaines d’annees avant de pouvoir identifier des variants genetiques responsables de ces phenotypes infectieux « extremes » chez l’Homme.