Arnaud W. Thille

Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients

PurposeSkin mottling is frequent and can be associated with an increased mortality rate in ICU patients with septic shock. Its overall incidence in ICU and its impact on outcome is unknown. We aimed to assess the incidence of skin mottling over the knee among all critically ill patients admitted in ICU and its role on their outcome.MethodsAn observational study over a 1-year period in a 15-bed medical ICU of a teaching hospital. Skin mottling over the knee was prospectively and qualitatively assessed by trained nurses.ResultsIncidence of skin mottling was 29% (230 of 791 patients) in overall, and 49% (32 of 65 patients) in the subset of patients admitted for septic shock. Skin mottling was present on the day on admission in 65% of patients and persisted more than 6xa0h in 59% of cases. In-ICU mortality was 8% in patients without mottling, 30% in patients with short skin mottling and 40% in patients with persistent skin mottling (pxa0<xa00.01 between all groups). In the overall population, skin mottling over the knee was associated with in-ICU mortality independently from SAPS II (aOR 3.29 [95% CI, 2.08–5.19], pxa0<xa00.0001). Among patients with skin mottling over the knee, persistence of skin mottling remained associated with increased in-ICU mortality independently of organ dysfunctions at the mottling onset (OR 2.77 [95% CI, 1.34–5.72], pxa0=xa00.004).ConclusionsSkin mottling is frequent in the general population of patients admitted in ICU. Occurrence and persistence of skin mottling are independently associated with in-ICU mortality.

High-flow nasal cannula oxygen therapy versus noninvasive ventilation in immunocompromised patients with acute respiratory failure: an observational cohort study.

BackgroundAcute respiratory failure is the main cause of admission to intensive care unit in immunocompromised patients. In this subset of patients, the beneficial effects of noninvasive ventilation (NIV) as compared to standard oxygen remain debated. High-flow nasal cannula oxygen therapy (HFNC) is an alternative to standard oxygen or NIV, and its use in hypoxemic patients has been growing. Therefore, we aimed to compare outcomes of immunocompromised patients treated using HFNC alone or NIV as a first-line therapy for acute respiratory failure in an observational cohort study over an 8-year period. Patients with acute-on-chronic respiratory failure, those treated with standard oxygen alone or needing immediate intubation, and those with a do-not-intubate order were excluded.ResultsAmong the 115 patients analyzed, 60 (52xa0%) were treated with HFNC alone and 55 (48xa0%) with NIV as first-line therapy with 30 patients (55xa0%) receiving HFNC and 25 patients (45xa0%) standard oxygen between NIV sessions. The rates of intubation and 28-day mortality were higher in patients treated with NIV than with HFNC (55 vs. 35xa0%, pxa0=xa00.04, and 40 vs. 20xa0%, pxa0=xa00.02 log-rank test, respectively). Using propensity score-matched analysis, NIV was associated with mortality. Using multivariate analysis, NIV was independently associated with intubation and mortality.ConclusionsBased on this observational cohort study including immunocompromised patients admitted to intensive care unit for acute respiratory failure, intubation and mortality rates could be lower in patients treated with HFNC alone than with NIV. The use of NIV remained independently associated with poor outcomes.

Brachyspira pilosicoli bloodstream infections: Case report and review of the literature

Brachyspira pilosicoli is the etiologic agent of human and animal intestinal spirochetosis and is rarely implicated as a cause of bacteremia. Here, we describe the case of a B. pilosicoli spirochetemia in a 53-year-old male patient suffering from cardiogenic shock. This fastidious bacterium was isolated from blood, likely after translocation from the intestinal tract. Blood cultures were positive after 5 days of incubation (one day after the patients death), highlighting the problem of the recovery of such type of fastidious bacterium. Identification was achieved by molecular methods (16S rRNA sequencing). A review of the English literature found only 8 cases of bacteremia caused by B. pilosicoli, mostly in immunocompromised or critically ill patients. Finally, difficulties in rapid and accurate diagnosis of B. pilosicoli bloodstream infections, in vitro antimicrobial susceptibility of human clinical isolates, and therapeutic options are discussed.

Left ventricular systolic dysfunction during septic shock: the role of loading conditions.

PurposeThe clinical significance of septic myocardial dysfunction is controversial, a fact that may be explained by the influence of loading conditions. Many indices may be useful to characterize cardiac function during septic shock, but their feasibility and physiological coherence in the clinical setting are unknown.MethodsHemodynamic and echocardiographic data with tissue Doppler and speckle tracking were prospectively recorded on the first 3xa0days of human septic shock. Hypokinesia, normokinesia, and hyperkinesia were defined as a left ventricular ejection fraction (LVEF) ofxa0<45, 45–60, andxa0>60%, respectively. Twelve hemodynamic indices exploring contractility and loading conditions were assessed and analyzed.ResultsTwo hundred and ninety-seven echocardiographies were performed in 132 patients. During the first 24xa0h (H1–24), 48 (36.4%) patients were hyperkinetic, 55 (41.7%) were normokinetic, and 29 (22.0%) patients were hypokinetic. Thirteen patients had a secondary hypokinesia absent at H1–24 but present at H25–48 or H49–72, for an overall incidence of 42 (31.8%) during the first 3xa0days. Despite a limited feasibility (<50%), global LV longitudinal peak systolic strain was impaired in a majority (>70%) of the patients assessed, including all those with depressed LVEF, and declined early in patients whose LVEF secondarily deteriorated. Most contractility indices were inversely correlated with afterload indices. Hyperkinetic patients exhibited the worst reduction in afterload indices. Hospital mortality was significantly higher in patients with LV hyperkinesia than in their counterparts: 30 (62.5%) vs. 35 (41.7%), pxa0=xa00.02.ConclusionsSpeckle tracking-derived strain was reduced in the majority of patients with septic shock, revealing covert septic myocardial dysfunction, but had poor feasibility. We found an inverse correlation between most of the contractility and afterload indices. Precise evaluation of afterload is crucial for adequate interpretation of LV systolic function in this setting.

Impact of sleep alterations on weaning duration in mechanically ventilated patients: a prospective study

Sleep is markedly altered in intensive care unit (ICU) patients and may alter respiratory performance. Our objective was to assess the impact of sleep alterations on weaning duration. We conducted a prospective physiological study at a French teaching hospital. ICU patients intubated for at least 24u2005h and difficult to wean were included. Complete polysomnography (PSG) was performed after the first spontaneous breathing trial failure. Presence of atypical sleep, duration of sleep stages, particularly rapid eye movement (REM) sleep, and electroencephalogram (EEG) reactivity at eyes opening were assessed by a neurologist. 20 out of 45 patients studied (44%) had atypical sleep that could not be classified according to the standard criteria. Duration of weaning between PSG and extubation was significantly longer in patients with atypical sleep (median (interquartile range) 5 (2–8) versus 2 (1–2)u2005days; p=0.001) and in those with no REM sleep compared with the others. Using multivariate logistic regression analysis, atypical sleep remained independently associated with prolonged weaning (>48u2005h after PSG). Altered EEG reactivity at eyes opening was a good predictor of atypical sleep. Our results suggest for the first time that brain dysfunction may have an influence on the ability to breathe spontaneously. ICU patients under mechanical ventilation with altered sleep had markedly longer weaning duration than did others http://ow.ly/BJip30jjag5

Severe but not mild hypercapnia affects the outcome in patients with severe cardiogenic pulmonary edema treated by non-invasive ventilation

BackgroundPatients with severe cardiogenic pulmonary edema (CPE) are frequently hypercapnic, possibly because of associated underlying chronic lung disease (CLD). Since hypercapnia has been associated with outcome, we aimed to identify factors associated to hypercapnia and its role on outcome of patients with CPE and no underlying CLD.MethodsObservational cohort study using data prospectively collected over a 3-year period. After excluding patients with any CLD or obstructive sleep apneas, all patients treated by non-invasive ventilation (NIV) for severe CPE were included. Hypercapnia was defined as PaCO2 >45 mmHg and non-rapid favorable outcome was defined as the need for intubation or continuation of NIV for more than 48 h.ResultsAfter excluding 60 patients with underlying CLD or sleep apneas, 112 patients were studied. The rates of intubation and of prolonged NIV were 6.3 % (n = 7) and 21.4 % (n = 24), respectively. Half of the patients (n = 56) had hypercapnia upon admission. Hypercapnic patients were older, more frequently obese, and were more likely to have a respiratory tract infection than non-hypercapnic patients. Hypercapnia had no influence on intubation rate or the need for prolonged NIV. However, patients with severe hypercapnia (PaCO2 >60 mmHg) needed longer durations of NIV and intensive care unit (ICU) stay than the others.ConclusionsAmong the patients admitted for severe CPE without CLD, half of them had hypercapnia at admission. Hypercapnic patients were older and more frequently obese but their outcome was similar compared to non-hypercapnic patients. Patients with severe hypercapnia needed longer durations of NIV than the others without increase in intubation rate.

Simple, difficult, or prolonged weaning: the most important factor is the success or failure of the first weaning trial.

A recent international consensus conference[1][1] published in 2007 proposed to categorize ventilated patients into 3 groups, based on the difficulty and duration of the weaning process: “simple weaning” (group 1) includes patients who succeed the first weaning trial and are extubated without

High-flow nasal cannula oxygen for reverting severe acute exacerbation of chronic obstructive pulmonary disease: A case report

High-flow nasal cannula (HFNC) oxygen therapy is a recent technique enabling delivery of high flow rate (up to 70 L/min) of gas heated and humidified as in physiological conditions. This strategy of oxygenation could be beneficial in ICU patients to avoid intubation in those with acute hypoxemic respiratory failure.1 The high-flow rate of gas continuously delivered in the airways may generate positive end-expiratory pressure (PEEP) effect2 and a washout of dead space, flushing carbon dioxide (CO2) out of the upper airways.3 This phenomenon may help to improve alveolar ventilation and to reduce work of breathing.4 To date, no study has been conducted to assess HFNC in acute hypercapnic respiratory failure. We report here the case of a 72-year-old male admitted to ICU for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) successfully treated with HFNC after failure of noninvasive ventilation (NIV). The history of this patient smoker with severe COPD (stage IV according to the GOLD classification) began 3 days prior to his admission with breathlessness worsening, fever and purulent cough. Clinical findings on admission to emergency department included signs of respiratory distress with a respiratory rate at 28 breaths/min and activation of accessory respiratory muscles. His temperature was

Echocardiographic detection of transpulmonary bubble transit during acute respiratory distress syndrome

BackgroundTranspulmonary bubble transit (TPBT) detected with contrast echocardiography is reported as a sign of intrapulmonary shunt during cirrhosis or exercise in healthy humans. However, its physiological meaning is not clear during acute respiratory distress syndrome (ARDS). Our aim was to determine the prevalence, significance, and prognosis of TPBT detection during ARDS.MethodsThis was a prospective observational study in an academic medical intensive care unit in France. Two hundred and sixteen consecutive patients with moderate-to-severe ARDS underwent transesophageal echocardiography with modified gelatine contrast. Moderate-to-large TPBT was defined as right-to-left passage of at least ten bubbles through a pulmonary vein more than three cardiac cycles after complete opacification of the right atrium. Patients with intra-cardiac shunt through patent foramen ovale were excluded.ResultsThe prevalence of moderate-to-large TPBT was 26% (including 42 patients with moderate and 15 with large TPBT). Patients with moderate-to-large TPBT had higher values of cardiac index and heart rate as compared to those without TPBT. There was no significant difference in PaO2/FIO2 ratio between groups, and TPBT was not influenced by end-expiratory positive pressure level in 93% of tested patients. Prevalence of septic shock was higher in the group with moderate-to-large TPBT. Patients with moderate-to-large TPBT had fewer ventilator-free days and intensive care unit-free days within the first 28 days, and higher in-hospital mortality as compared to others.ConclusionsModerate-to-large TPBT was detected with contrast echocardiography in 26% of patients with ARDS. This finding was associated with a hyperdynamic and septic state, but did not influence oxygenation.

Trends in use and benefits of non-invasive ventilation as first-line therapy in acute respiratory failure.

Dear Editor, In a recent paper examining trends in the use and outcome of non-invasive mechanical ventilation (NIV) in acute respiratory failure (ARF) over a 15-year period (1997–2011) in 14 French intensive care units (ICUs), Schnell and colleagues [1] report a steady increase in the use of NIV as first-line ventilatory support, reaching 42 % in 2011. We recently reported the rates of intubation in hypercapnic [2] or hypoxemic patients [3] receiving NIV as first-line therapy in our ICU over a 3-year period: 430 patients, i.e., more than 140 patients per year (after excluding 35 patients with a ‘‘do not resuscitate’’ order) received NIV as first-line ventilatory support for respiratory failure of any cause (Fig. 1). In comparison, the study by Schnell et al. included 974 patients over a 15-year period, i.e., 5–10 patients per center and per year, bringing into question the representativeness of their cohort. Schnell and colleagues [1] report intubation rates of 21 and 18 % in patients with acute-on-chronic respiratory failure and in those with cardiogenic pulmonary edema, respectively. In our cohort, the rates of intubation were markedly lower both in patients with acute-onchronic respiratory failure (15 %) and in those with cardiogenic pulmonary edema (only 6 %), possibly due to a high NIV-case volume. By contrast, the overall intubation rate was 51 % in our patients with de novo ARF (Fig. 1), which is markedly higher than the 34 % rate reported by Schnell et al., suggesting that NIV was probably initiated in more severe patients in our center. Indeed, 58 % of our patients with ARF received first-line NIV. Similarly, a 46 % intubation rate in patients with de novo ARF receiving first-line NIV was recently reported from other highly skilled centers [4, 5]. Therefore, an approximately 45–50 % intubation rate could be the reference in the most severe hypoxemic patients, even in experienced units. Carrillo and colleagues reported that delayed intubation was associated with a poor prognosis [4]. However, we did not confirm these results when using predefined intubation criteria and a shorter time to intubation [3]. As all of the above studies found an