Catherine Paugam-Burtz

Daily organ-system failure for diagnosis of persistent intra-abdominal sepsis after postoperative peritonitis

Abstract.Objective: To evaluate the time-course of two organ failure scores (SOFA and Goris) after surgery for postoperative peritonitis in critically ill patients according to the persistence/nonpersistence of intraabdominal sepsis (IAS). Design: Retrospective study. Patients: Sixty-two consecutive patients (SAPSII = 38±14) admitted in the surgical ICU. Methods: Patients were classified according to the persistence of IAS (IAS+, n=36) confirmed by a second laparotomy or the lack of IAS (IAS-, n=26) assessed by a favorable 30-day evolution without reintervention. Scores were calculated daily from day 0 preoperatively to postoperative day 5. Results: In both groups, SOFA scores were higher on day 1 when compared to day 0 (8.3±3.1 vs 6.1±3.7 in the IAS+ group and 5.2±3.4 vs 2.7±2.7 in the IAS- group). In the IAS- patients, the SOFA score displayed a decrease starting on day 2 when compared to day 1 (4.4±3.6 vs 5.2±3.4, P=0.03). In contrast, in the IAS+ patients, the SOFA score remained unchanged until day 5. The time course of the Goris score was strictly similar to the SOFA scores. Conclusion: In critically ill patients with postoperative peritonitis, the postoperative time course of the SOFA and the Goris organ failure scores was different between patients with or without intra-abdominal persistent sepsis. The lack of improvement of one of these scores on postoperative day 2 may suggest persistent intraabdominal sepsis and supports the need for a new surgical exploration.

Early‐onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Early‐onset hospital‐acquired pneumonia (E‐HAP) is one of the leading causes of sepsis and mortality after liver transplantation (LT). The appropriate antimicrobial therapy is crucially important for surviving sepsis in this context. The aim of this study was to analyze microbiological findings, associated factors, and optimal antibiotic regimens for E‐HAP after LT. Patients demonstrating E‐HAP in a single‐center cohort of 148 LT recipients were prospectively detected. The diagnosis of pneumonia relied on a combination of supportive clinical findings and a positive culture of a lower respiratory tract sample. E‐HAP was considered present if pneumonia occurred within 6 days of intensive care unit (ICU) admission after LT. Twenty‐three patients (15.5%) developed E‐HAP, which were caused by 36 pathogens (61.1% were gram‐negative bacilli, and 33.3% were classified as hospital‐acquired). For patients who developed E‐HAP, the duration of mechanical ventilation and the ICU stay were significantly longer. Despite a trend toward higher mortality at any time in the E‐HAP group, there was no significant difference in mortality between patients with E‐HAP and patients without E‐HAP. Lactatemia, vasopressor requirements, Simplified Acute Physiology Score II (SAPS II) score on ICU admission, and mechanical ventilation lasting more than 48 hours after LT were associated with E‐HAP. Combinations of broad‐spectrum β‐lactams and aminoglycosides were active against more than 91% of the encountered pathogens. However, antibiotic de‐escalation was possible in more than one‐third of cases after identification of the pathogens. In conclusion, E‐HAP after LT is a severe condition that appears to be influenced by physiological derangements induced by the surgery, such as lactatemia, vasopressor requirements, and mechanical ventilation requirements, as well as the postoperative SAPS II score. At the time of treatment initiation, an antimicrobial regimen usually proposed for late‐onset pneumonia should be followed. Liver Transpl 16:1178–1185, 2010.

Microbiological findings of culture-positive preservation fluid in liver transplantation.

S. Janny, F. Bert, F. Dondero, F. Durand, P. Guerrini, P. Merckx, M.H. Nicolas‐Chanoine, J. Belghiti, J. Mantz, C. Paugam‐Burtz. Microbiological findings of culture‐positive preservation fluid in liver transplantation.
Transpl Infect Dis 2011: 13: 9–14. All rights reserved

Risk factors associated with preoperative fecal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae in liver transplant recipients.

The aim of the study was to identify risk factors associated with pre‐transplant fecal carriage of extended‐spectrum β‐lactamase (ESBL)‐producing Enterobacteriaceae in liver transplant recipients.

Molecular epidemiology of Escherichia coli bacteremia in liver transplant recipients

F. Bert, B. Huynh, F. Dondero, J.R. Johnson, C. Paugam‐Burtz, F. Durand, J. Belghiti, D. Valla, R. Moreau, M.‐H. Nicolas‐Chanoine. Molecular epidemiology of Escherichia coli bacteremia in liver transplant recipients.
Transpl Infect Dis 2011: 13: 359–365. All rights reserved

Assessment of the external validity of a predictive score for blood transfusion in liver surgery

BACKGROUND Perioperative bleeding is a predictor of morbidity following liver resection. The transfusion-related score (TRS), which is derived from five variables (cirrhosis, preoperative haemoglobin level, tumour size, vena cava exposure and associated extraliver surgical procedure), has been proposed to predict the likelihood of transfusion in liver resection. OBJECTIVE The purpose of this observational study was to evaluate the external validity of the TRS. METHODS In a retrospective, monocentre, observational cohort study of patients undergoing elective liver resection surgery, data for transfused and non-transfused patients were compared by univariate analysis. The TRS was calculated for each patient. The frequency of transfusion was calculated for each score level. The accuracy of the TRS was evaluated using the area under the receiver operator characteristic curve (AUC). RESULTS A total of 205 patients submitted to liver resection were included. Of these, 48 (23.4%) patients received a blood transfusion. There was no significant difference between transfused and non-transfused patients in age, American Society of Anesthesiologists (ASA) score or cirrhosis. The AUC for the TRS was 0.68 (95% confidence interval 0.59-0.77). Among TRS items, only vena cava exposure and associated surgical procedures were significantly associated with risk for transfusion. CONCLUSIONS In the present population, the TRS appeared to serve as a weak predictor of perioperative transfusion. This study confirms that the external validity of the transfusion predictive score should be subject to further investigation before it can be implemented in clinical use.

Cirrhose et risque opératoire

Major surgery in cirrhotic patient is associated with an increased risk of postoperative morbidity and mortality. This risk increases with the disease severity. Cirrhosis generates a wide variety of organ dysfunctions including hemostasis abnormalities, cardiocirculatory and renal dysfunctions. These modifications facilitate postoperative complications. Postoperative morbidity includes surgical site complications such as sepsis or haemorrhage and organ complications such as pneumonia, kidney injury, hepatic failure or ascite. Perioperative care in cirrhotic patient can probably be improved by various techniques such as perioperative nutritional support, intraoperative hemodynamic optimization and close postoperative monitoring. Optimal perioperative care of patients with endstage liver disease necessitates collaboration between anesthesiologists, hepatologists and surgeons in charge of the patient. Indeed, they should be aware of any discussion about possible liver transplantation.