Agnès Bonadona

Safety of intrahospital transport in ventilated critically ill patients: a multicenter cohort study*.

Objectives:To describe intrahospital transport complications in critically ill patients receiving invasive mechanical ventilation. Design:Prospective multicenter cohort study. Setting:Twelve French ICUs belonging to the OUTCOMEREA study group. Patients:Patients older than or equal to 18 years old admitted in the ICU and requiring invasive mechanical ventilation between April 2000 and November 2010 were included. Interventions:None. Measurements and Main Results:Six thousand two hundred forty-two patients on invasive mechanical ventilation were identified in the OUTCOMEREA database. The statistical analysis included a description of demographic and clinical characteristics of the cohort, identification of risk factors for intrahospital transport and construction of an intrahospital transport propensity score, and an exposed/unexposed study to compare complication of intrahospital transport (excluding transport to the operating room) after adjustment on the propensity score, length of stay, and confounding factors on the day before intrahospital transport. Three thousand and six intrahospital transports occurred in 1,782 patients (28.6%) (1–17 intrahospital transports/patient). Transported patients had higher admission Simplified Acute Physiology Score II values (median [interquartile range], 51 [39–65] vs 46 [33–62], p < 10–4) and longer ICU stay lengths (12 [6–23] vs 5 [3–11] d, p < 10–4). Post-intrahospital transport complications were recorded in 621 patients (37.4%). We matched 1,659 intrahospital transport patients to 3,344 nonintrahospital transport patients according to the intrahospital transport propensity score and previous ICU stay length. After adjustment, intrahospital transport patients were at higher risk for various complications (odds ratio = 1.9; 95% CI, 1.7–2.2; p < 10–4), including pneumothorax, atelectasis, ventilator-associated pneumonia, hypoglycemia, hyperglycemia, and hypernatremia. Intrahospital transport was associated with a longer ICU length of stay but had no significant impact on mortality. Conclusions:Intrahospital transport increases the risk of complications in ventilated critically ill patients. Continuous quality improvement programs should include specific procedures to minimize intrahospital transport-related risks.

New materials and devices for preventing catheter-related infections

Catheters are the leading source of bloodstream infections for patients in the intensive care unit (ICU). Comprehensive unit-based programs have proven to be effective in decreasing catheter-related bloodstream infections (CR-BSIs). ICU rates of CR-BSI higher than 2 per 1,000 catheter-days are no longer acceptable. The locally adapted list of preventive measures should include skin antisepsis with an alcoholic preparation, maximal barrier precautions, a strict catheter maintenance policy, and removal of unnecessary catheters. The development of new technologies capable of further decreasing the now low CR-BSI rate is a major challenge. Recently, new materials that decrease the risk of skin-to-vein bacterial migration, such as new antiseptic dressings, were extensively tested. Antimicrobial-coated catheters can prevent CR-BSI but have a theoretical risk of selecting resistant bacteria. An antimicrobial or antiseptic lock may prevent bacterial migration from the hub to the bloodstream. This review discusses the available knowledge about these new technologies.

New challenges in the diagnosis, management, and prevention of central venous catheter-related infections.

Catheters are the leading source of bloodstream infections in critically ill patients. Because the clinical signs of infection are nonspecific, such infections are overly suspected, which results in unnecessary removal of catheters. A conservative approach might be attempted in mild infections, whereas catheters should always be removed in cases of severe sepsis or septic shock. Nowadays, comprehensive unit-based improvement programs are effective to reduce catheter-related bloodstream infections (CR-BSIs). Rates of CR-BSI higher than 2 per 1000 catheter-days are no longer acceptable. A locally adapted checklist of preventive measures should include cutaneous antisepsis with alcoholic preparation, maximal barrier precaution, strict policy of catheter maintenance, and ablation of useless catheters. Antiseptic dressings and, to a lesser extent, antimicrobial-coated catheters, might be added to the prevention strategies if the level of infections remains high despite implementation of a prevention program. In the case of CR-BSI in intensive care units (ICUs), the catheter should be removed. In the case of persistence of fever or positive blood cultures after 3 days, inadequate antibiotic therapy, endocarditis, or thrombophlebitis should be ruled out.

Pulmonary embolism in mechanically ventilated patients requiring computed tomography: Prevalence, risk factors, and outcome.

Objective:To estimate the rate of pulmonary embolism among mechanically ventilated patients and its association with deep venous thrombosis. Design:Prospective cohort study. Setting:Medical intensive care unit of a university-affiliated teaching hospital. Patients:Inclusion criteria: mechanically ventilated patients requiring a thoracic contrast-enhanced computed tomography scan for any medical reason. Exclusion criteria: a diagnosis of pulmonary embolism before intensive care unit admission, an allergy to contrast agents, and age younger than 18 yrs. Interventions:All the mechanically ventilated patients requiring a thoracic computed tomography underwent the standard imaging protocol for pulmonary embolism detection. Therapeutic anticoagulation was given immediately after pulmonary embolism diagnosis. All the included patients underwent a compression ultrasound of the four limbs within 48 hrs after the computed tomography scan to detect deep venous thrombosis. Results:Of 176 included patients, 33 (18.7%) had pulmonary embolism diagnosed by computed tomography, including 20 (61%) with no clinical suspicion of pulmonary embolism. By multiple logistic regression, independent risk factors for pulmonary embolism were male gender, high body mass index, history of cancer, past medical history of deep venous thrombosis, coma, and high platelet count. Previous prophylactic anticoagulant use was not a risk factor for pulmonary embolism. Of the 176 patients, 35 (19.9%) had deep venous thrombosis by compression ultrasonography, including 20 (57.1%) in the lower limbs and 24 (68.6%) related to central venous catheters. Of the 33 pulmonary embolisms, 11 (33.3%) were associated with deep venous thrombosis. The pulmonary embolism risk was increased by lower-limb deep venous thrombosis (odds ratio 4.0; 95% confidence interval 1.6–10) but not upper-limb deep venous thrombosis (odds ratio 0.6; 95% confidence interval 0.1–2.9). Crude comparison of patients with and without pulmonary embolism shows no difference in length of stay or mortality. Conclusions:In mechanically ventilated patients who needed a computed tomography, pulmonary embolism was more common than expected. Patients diagnosed with pulmonary embolism were all treated with therapeutic anticoagulation, and their intensive care unit or hospital mortality was not impacted by the pulmonary embolism occurrence. These results invite further research into early screening and therapeutic anticoagulation of pulmonary embolism in critically ill patients.

Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.

[Non-fatal disseminated mucormycosis in a solid organ transplant]

BACKGROUND Mucormycosis is a rare fungal infection occurring most frequently in immunocompromised patients. The pathogens are filamentous fungi, order of Mucorales. Disseminated mucormycosis is a severe, life treating disease. Early diagnosis is a major determinant for prognosis, however, it remains difficult. The management consists in an early antifungal therapy using lipid formulation of amphotericin B associated with an extensive surgical debridement. Despite this therapeutic of choice, the mortality of disseminated mucormycosis remains high. OBSERVATION We report the case of disseminated mucormycosis in a 25 years old woman 9 months after a pulmonary transplantation. The clinical presentation included pulmonary and thyroid localization and the pathogen was Absidia corymbifera. The patient survived thanks to a large surgical debridement, and an early antifungal bitherapy by lipid formulation of amphotericin B and posaconazole. CONCLUSION The re-emergence and the high mortality of mucormycosis in solid organ transplant receiver show the necessity to find new therapeutic approaches. Posaconazole associated with liposomal amphotericin B could be an interesting option to treat disseminated mucormycosis and improve their outcome.

Lethal 5-fluorouracil toxicity in a colorectal patient with severe dihydropyrimidine dehydrogenase (DPD) deficiency

Dear Editor: Fluoropyrimidines are widely used in oncology. 5Fluorouracil (5-FU) is the reference drug in the treatment of more than 50 % of the gastrointestinal, gynecological, and upper aerodigestive tract cancers. As most of anti-cancer drugs, it has a narrow therapeutic index leading to organ toxicities that could be lethal in 0.5 % of cases. Toxicity is linked to some specific parameters to patients (age, comorbidities, treatment duration) and genetic polymorphisms that can affect dihydropyrimidine dehydrogenase (DPD) key enzyme of fluoropyrimidine catabolism. Some mutations significantly modify DPD activity with more or less clinical impact. We report the clinical course and outcome of a 63-year-old woman exhibiting a complete DPD deficiency, leading to death after administration of only one standard dose of 5-FU infusion.

Mucormycose disséminée d’évolution favorable chez une greffée pulmonaire

Resume Introduction Les mucormycoses sont des infections fongiques rares survenant surtout chez les immunodeprimes. Elles sont dues a des champignons filamenteux de type Mucorales . Les formes disseminees sont le plus souvent fatales. Le diagnostic, souvent difficile, doit etre le plus precoce possible. La prise en charge consiste a instaurer rapidement un traitement antifongique avec la formulation lipidique d’amphotericine B et a realiser un large debridement chirurgical. En depit d’un traitement optimal, la mortalite liee aux mucormycoses reste tres importante. Observation Nous rapportons un cas de mucormycose disseminee chez une patiente de 25 ans transplantee pulmonaire depuis neuf mois. Il existait une atteinte pulmonaire et thyroidienne due a Absidia corymbifera . La patiente a survecu grâce a une chirurgie elargie, cervicale et thoracique, et a une bitherapie antifongique precoce associant la formulation lipidique d’amphotericine B et posaconazole. Conclusion L’emergence des mucormycoses chez les patients transplantes et leur mortalite importante incitent a trouver de nouvelles alternatives therapeutiques. L’association du posaconazole avec la formulation lipidique d’amphotericine B pourrait presenter un interet dans le traitement des mucormycoses disseminees.