Annick Legras

Respiratory pulse pressure variation fails to predict fluid responsiveness in acute respiratory distress syndrome

IntroductionFluid responsiveness prediction is of utmost interest during acute respiratory distress syndrome (ARDS), but the performance of respiratory pulse pressure variation (ΔRESPPP) has scarcely been reported. In patients with ARDS, the pathophysiology of ΔRESPPP may differ from that of healthy lungs because of low tidal volume (Vt), high respiratory rate, decreased lung and sometimes chest wall compliance, which increase alveolar and/or pleural pressure. We aimed to assess ΔRESPPP in a large ARDS population.MethodsOur study population of nonarrhythmic ARDS patients without inspiratory effort were considered responders if their cardiac output increased by >10% after 500-ml volume expansion.ResultsAmong the 65 included patients (26 responders), the area under the receiver-operating curve (AUC) for ΔRESPPP was 0.75 (95% confidence interval (CI95): 0.62 to 0.85), and a best cutoff of 5% yielded positive and negative likelihood ratios of 4.8 (CI95: 3.6 to 6.2) and 0.32 (CI95: 0.1 to 0.8), respectively. Adjusting ΔRESPPP for Vt, airway driving pressure or respiratory variations in pulmonary artery occlusion pressure (ΔPAOP), a surrogate for pleural pressure variations, in 33 Swan-Ganz catheter carriers did not markedly improve its predictive performance. In patients with ΔPAOP above its median value (4 mmHg), AUC for ΔRESPPP was 1 (CI95: 0.73 to 1) as compared with 0.79 (CI95: 0.52 to 0.94) otherwise (P = 0.07). A 300-ml volume expansion induced a ≥2 mmHg increase of central venous pressure, suggesting a change in cardiac preload, in 40 patients, but none of the 28 of 40 nonresponders responded to an additional 200-ml volume expansion.ConclusionsDuring protective mechanical ventilation for early ARDS, partly because of insufficient changes in pleural pressure, ΔRESPPP performance was poor. Careful fluid challenges may be a safe alternative.

Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy ☆

PURPOSE Data regarding outcome of patients with chronic liver disease with severe hepatic encephalopathy in intensive care unit are currently scarce. METHODS This study is a retrospective observational case series in a medical intensive care unit (ICU) in a university hospital from 1995 to 2005. Patients with hepatic encephalopathy (HE) (admitted with or developing) were identified. Clinical and laboratory parameters were analyzed to determinate predictors of ICU and 1-year mortality. RESULTS Seventy-one patients were included (53 male). Median Simplified Acute Physiology Score was 56 with Child-Pugh score 11 +/- 2. Seventy-six percent of patients were admitted with coma (Glasgow Coma Scale, 7.7 +/- 4). Eighty-two percent of patients required intubation, and 28% vasopressors. Thirty-five percent died during ICU stay. At 1 year, mortality was 54%. Univariate analysis identified arterial hypotension, mechanical ventilation, vasopressors at any time, acute renal failure, Simplified Acute Physiology Score, and sepsis associated with ICU mortality. In multivariate analysis, vasopressor use or acute renal failure was the main independent predictor of ICU death and 1-year mortality. Patients free of these risk factors, even requiring intubation, were identified as isolated HE, with lower mortality rates. CONCLUSION Predictors of outcome were similar to other groups of patients with liver disease admitted for other reasons. Intensive care unit mortality was lower than reported for other groups of patients with similar illness. Patients with severe HE admitted to ICU with no organ dysfunction other than mechanical ventilation had a better outcome and may require ICU admission.

Tracking Hypotension and Dynamic Changes in Arterial Blood Pressure with Brachial Cuff Measurements

BACKGROUND: Arterial cannulation is strongly recommended during shock. Nevertheless, this procedure is associated with significant risks and may delay other emergent procedures. We assessed the discriminative power of brachial cuff oscillometric noninvasive blood pressure (NIBP) for identifying patients with an invasive mean arterial blood pressure (MAP) below 65 mm Hg or increasing their invasive MAP after cardiovascular interventions. METHODS: This prospective study, conducted in three intensive care units, included adults in circulatory failure who underwent 45° passive leg raising, 300 mL fluid loading, and additional 200 mL fluid loading. The collected data were four invasive and noninvasive MAP measurements at each study phase. RESULTS: Among 111 patients (50 septic, 15 cardiogenic, and 46 other source of shock), when averaging measurements of each study phase, NIBP measurements accurately predicted an invasive MAP lower than 65 mm Hg: area under the receiver operating characteristic curve 0.90 (95% CI: 0.71–1), positive and negative likelihood ratios 7.7 (95% CI: 5.4–11) and 0.31 (95% CI: 0.22–0.44) (cutoff 65 mm Hg). For identifying patients increasing their invasive MAP by more than 10%, the area under the receiver operating characteristic curve was 0.95 (95% CI: 0.92–0.96); positive and negative likelihood ratios (cutoff 10%) were 25.7 (95% CI: 10.8–61.4) and 0.26 (95% CI: 0.2–0.34). CONCLUSIONS: NIBP measurements have a good discriminative power for identifying hypotensive patients and performed even better in tracking MAP changes, provided that one averages four NIBP measurements.

A multicentre case-control study of nonsteroidal anti-inflammatory drugs as a risk factor for severe sepsis and septic shock

IntroductionWe aimed to establish whether the use of nonsteroidal anti-inflammatory drugs (NSAIDs) during evolving bacterial community-acquired infection in adults is associated with severe sepsis or septic shock.MethodsWe conducted a multicentre case-control study in eight intensive care units. Cases were all adult patients admitted for severe sepsis or septic shock due to a bacterial community-acquired infection. Control individuals were patients hospitalized with a mild community-acquired infection. Each case was matched to one control for age, presence of diabetes and site of infection.ResultsThe main outcome measures were the proportions of cases and controls exposed to NSAIDs or aspirin during the period of observation. In all, 152 matched pairs were analyzed. The use of NSAIDs or aspirin during the observation period did not differ between cases and controls (27% versus 28; odds ratio = 0.93, 95% confidence interval [CI] = 0.52 to 1.64). If aspirin was not considered or if a distinction was made between acute and chronic drug treatment, there remained no difference between groups. However, the median time to prescription of effective antibiotic therapy was longer for NSAID users (6 days, 95% CI = 3 to 7 days) than for nonusers (3 days, 95% CI = 2 to 3 days; P = 0.02).ConclusionsIn this study, the use of NSAIDs or aspirin during evolving bacterial infection was frequent and occurred in one-quarter of the patients with such infection. Although the use of NSAIDs by patients with severe sepsis or septic shock did not differ from their use by those with mild infection at the same infected site, we observed a longer median time to prescription of effective antibiotic therapy in NSAID users.

Aborted Sudden Cardiac Death Revealing Isolated Noncompaction of the Left Ventricle in a Patient with Wolff-Parkinson-White Syndrome

Isolated noncompaction of the left ventricle (INLV) is a rare congenital disorder associated with multiple cardiac arrhythmias. We report a case of INLV revealed by ventricular fibrillation in a patient with Wolff‐Parkinson‐White syndrome. Because of the persistence of inducible ventricular arrhythmias after ablation of the accessory pathway, implantation of an ICD was decided.

Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited

Sir: It has been proposed that severely hypoxemic patients be ventilated in the prone position, in an attempt to improve gas exchange [1]. Testing this position in patients with the acute respiratory distress syndrome (ARDS) is recommended [21. However, no guidelines are available for cases of life-threatening events occurring with the patient in the prone position especially cardiac arrest. We report a case of successful cardiopulmonary resuscitation of a patient ventilated in the prone position, without changing the patients position. A 48-year-old man was being ventilated for community-acquired pneumonia. His gas exchange (partial pressure of oxygen in arterial blood 4.3 kPa and of carbon dioxide 16.4 kPa and pH 7.14) deteriorated despite controlmode ventilation with 10 cmH20 positive end-expiratory pressure, 100 p. 100 fractional inspired oxygen, and 20 ppm inhaled nitric oxide. He was then turned to the prone position. A few minutes later, asytole developed and blood pressure became unobtainable. Cardiac massage was begun immediately with the patient in the prone position. One physician placed the flat of one hand under the patients sternum, while another physician compressed the mid-thoracic spine rhythmically with both hands (Fig. 1). Arterial radial blood pressure was maintained at least at 80/35 mmHg throughout resuscitation. Epinephrine (1 mg i.v.) was injected twice at a 3-min interval. Five minutes after starting cardiac compression, sinus rhythm resumed and blood pressure was maintained at 140/85 mmHg. Gas exchange dramatically improved a few hours later. Seven days after the incident, the patient was awake and well oriented. The conventional approach of closed chest compression is well established with the patient in the supine position [3]. However, cardiac massage might be required for patients in the prone position, e.g., during anesthesia for spinal or posterior fossa surgery. Three cases of successful resuscitation have been reported in these circumstances [4, 5] in which resuming the supine position might have injured the brain or spinal cord. Changing the position has some other drawbacks for ARDS patients ventilated in the prone position: (a) it is time consuming and delays initiation of cardiac massage; (b) moving the patient into the supine position without proper protection may induce certain complications, e.g., accidental extubation, dislodging the venous catheter, or shoulder injury to the patient; (c) turning a patient from one position into another requires at least four members of staff, who are not always immediately available in emergency situations. For these reasons, we suggest trying the

Randomized comparison of 2 protocols to prevent acquisition of methicillin-resistant Staphylococcus aureus: results of a 2-center study involving 500 patients.

OBJECTIVE To compare an interventional protocol with a standard protocol for preventing the acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in the intensive care unit (ICU). DESIGN Prospective, randomized, controlled, parallel-group, nonblinded clinical trial. SETTING Medical ICUs of 2 French university hospitals. PARTICIPANTS Five hundred adults with an expected length of stay in the ICU greater than 48 hours. INTERVENTIONS For the intervention group, the protocol required repeated MRSA screening, contact and droplet isolation precautions for patients at risk for MRSA at ICU admission and for MRSA-positive patients, and decontamination with nasal mupirocin and chlorhexidine body wash for MRSA-positive patients. For the standard group, the standard precautions protocol was used, and the results of repeated MRSA screening in the standard group were not communicated to investigators. MAIN OUTCOME MEASURE MRSA acquisition rate in the ICU. An audit was conducted to assess compliance with hygiene and isolation precautions. RESULTS In the intent-to-treat analysis ([Formula: see text]), the MRSA acquisition rate in the ICU was similar in the standard (13 [5.3%] of 243) and intervention (16 [6.5%] of 245) groups ([Formula: see text]). The audit showed that the overall compliance rate was 85.5% in the standard group and 84.1% in the intervention group ([Formula: see text]), although compliance was higher when isolation precautions were absent than when they were in place (88.2% vs 79.1%; [Formula: see text]). MRSA incidence rates were higher without isolation precautions (7.57‰) than with isolation precautions (2.36‰; [Formula: see text]). CONCLUSIONS Individual allocation to MRSA screening, isolation precautions, and decontamination do not provide individual benefit in reducing MRSA acquisition, compared with standard precautions, although the collective risk was lower during the periods of isolation. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT00151606.

Right-to-left interatrial shunt in ARDS: dramatic improvement in prone position

Abstract The mechanisms leading to shunting through a patent foramen ovale include high right-sided cardiac pressures and respiratory factors due to mechanical ventilation and also anatomical changes in the right atrium as described in the platypnea-orthodeoxia syndrome. We report a patient with the adult respiratory distress syndrome (ARDS) who had a right-to-left atrial shunt which decreased in the prone position, after which oxygenation improved. The patient was admitted to the intensive care unit because of ARDS due to an invasive fungal infection. He had a history of chronic lymphocytic leukemia and paradoxical embolisms through a patent foramen ovale. Despite mechanical ventilation and antifungal treatment he developed severe ARDS. He was therefore turned to the prone position. Blood gas values improved dramatically (arterial oxygen tension/fractional inspired oxygen ratio increasing from 59 to 278 torr). Transcranial Doppler sonography was performed with bubble study, which confirmed a massive right-to-left shunt in the supine position and which instantaneously decreased in the prone position. This case suggests that a decrease in right-to-left shunt in patients who have a patent foramen ovale could partly explain the improvement in hypoxemia in the prone position.

Clinical and economic outcomes of infective endocarditis

Abstract Background: In France, the estimated annual incidence of infective endocarditis (IE) is 33.8 cases per million residents. Valvular surgery is frequently undergone. We report an epidemiological and economic study of IE for 2007–2009 in a French region, using the hospital discharge database (HDD). Methods: The population studied concerned all the patients living in Centre region, France, hospitalized for IE. We extracted hospital stay data for IE from the regional HDD, with a definition based on IE-related diagnosis codes. The predictive positive value (PPV) and sensitivity (Se) of the definition were 87.4% and 90%, respectively, according to the Duke criteria (definite IE frequency 74.4%). Hospitalization costs were estimated, taking into account the fixed hospital charges of the diagnosis-related group (DRG) and supplementary charges due to intensive care unit (ICU) stay. Results: The analysis included 578 patients. The annual average incidence was 45.4 cases per million residents. Valvular surgery was performed in 19.4% of cases. The hospital mortality was 17.6%. Multivariate analysis identified as risk factors for mortality an age ≥ 70 years (odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.78–5.18), staphylococcal IE (OR = 3.3, 95% CI = 1.9–5.7), chronic renal insufficiency (OR = 2.04, 95% CI = 1.00–4.15), ischemic stroke (OR = 2.55, 95% CI = 1.19–5.47), and hemorrhagic stroke (OR = 5.7, 95% CI = 1.9–17.3). The average cost per episode was

Atteinte respiratoire sévère et choc septique à Mycobacterium bovis: Une complication rare de la BCG thérapie intravésicale

20 103 (€15 281). Conclusions: We report a higher incidence of IE than described by the French national study of 2008. Valvular surgery was considerably less frequent than in the published data, whereas mortality was similar. IE generates substantial costs.