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Usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest with extracorporeal life support.

AIM To evaluate the usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest patients with extracorporeal life support (ECLS). METHODS Sixty-six adults with witnessed cardiac arrest of cardiac origin unrelated to poisoning or hypothermia undergoing cardiopulmonary resuscitation without return of spontaneous circulation (duration: 155 min [120-180], median, [25-75%-percentiles]) were included in a prospective cohort-study. ECLS was implemented under cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane-oxygenator, aiming to maintain ECLS flow ≥ 2.5 l/min and mean arterial pressure ≥ 60 mm Hg. RESULTS Forty-seven of 66 patients died within 24 h from multiorgan failure and massive capillary leak. Of 19/66 patients who survived ≥ 24 h with stable circulatory conditions permitting neurological evaluation, four became conscious and were transferred for further cardiac assistance, while three became organ donors. Ultimately, one patient survived without neurologic sequelae after cardiac transplantation. Using multivariate analysis, only pre-cannulation peripheral venous oxygen saturation (SpvO₂, 28% [15-52]) independently predicted inability to maintain targeted ECLS conditions ≥ 24 h (odds ratio for each 10%-decrease [95%-confidence interval]: 1.65 [1.21; 2.25], p=0.002). The area under the receiver-operating-characteristics curve was 0.78 [0.63; 0.93]. SpvO₂ cut-off value of 33% was associated with a sensitivity of 0.68 [0.50; 0.83] and specificity of 0.81 [0.54; 0.96]. SpvO₂ ≤ 8%, lactate concentration ≥ 21 mmol/l, fibrinogen ≤ 0.8 g/l, and prothrombin index ≤ 11% predicted premature ECLS discontinuation with a specificity of 1. CONCLUSION SpvO₂ is useful to predict the inability of maintaining refractory cardiac arrest victims on ECLS without detrimental capillary leak and multiorgan failure until neurological evaluation.

The French airbridge for circulatory support in the Carribean

OBJECTIVES We report the assessment and the activities for the first year of our airborne circulatory support mobile unit (CSMU) in the French Caribbean. METHODS From January 2010 to June 2011, 12 patients (mean age = 35.7 years; range: 15-62 years; sex ratio = 1:1) were attended outside Martinique by our CSMU and transferred to our unit by air. RESULTS Eight patients had acute respiratory distress syndrome and were assisted by veno-venous extra corporeal membrane oxygenation (ECMO) four had refractory cardiogenic shock, assisted by extra corporeal life support (ECLS). The average air transfer distance for patients was 912 km (range: 198-1585 km). The average flying time was 124 min (range: 45-255 min). The aircraft used were helicopter, military transport or private jet. The setting-up of assistance devices and transfer of patients was uneventful. One patient subsequently benefited from heart transplantation after long-term circulatory support. One patient died under ECMO support after 51 days of assistance and another died on the 60th day after withdrawal of ECLS. CONCLUSIONS CSMUs can be very efficient in providing support to patients in refractory shock, when remote from a cardiac surgery centre. The airborne transfer of patients on ECMO/ECLS can be achieved safely, even over long distances.

Bothrops lanceolatus Bites: Guidelines for Severity Assessment and Emergent Management

Approximately 20-30 declared snakebite cases occurin Martinique each year. Bothrops lanceolatus, a member of the Crotalidae family, is considered to be the only involved snake. B. lanceolatus, commonly named “Fer-de-Lance”, is endemic and only found on this Caribbean island. Envenomation local features include the presence of fang marks, swelling, pain, bleeding from punctures, and ecchymosis. Severe envenomation is associated with multiple systemic thromboses appearing within 48 h of the bite and resulting in cerebral, myocardial or pulmonary infarctions. Diagnosis requires first of all identification of the snake. Coagulation tests are helpful to identify thrombocytopenia or disseminated intravascular coagulation. A clinical score based on 4 grades is helpful to assess envonimation severity. A specific monovalent equine anti-venom (Bothrofav®, Sanofi-Pasteur, France) to neutralize B. lanceolatus venom is available. Its early administration within 6h from the biting in case of progressive local injures, general signs or coagulation disturbances is effective to prevent severe thrombosis and coagulopathy. Its tolerance is considered to be good. Despite an increasing incidence of bites, no deaths have been recently attributed to B. lanceolatus in Martinique, probably due to the currently recommended strategy of early antivenom administration when required.

Intoxication aiguë à l’hydroxychloroquine: Danger d’une correction exagérée ou rapide de l’hypokaliémie initiale

INTRODUCTION Toxic effects of hydroxychloroquine, like chloroquine, include membrane stabilization and hypokalemia, which is correlated with the severity of the overdose. Correction of hypokalemia can expose patients to the risk of ventricular arrhythmia. CASE A 19-year-old woman who had ingested 6 grams of hydroxychloroquine was admitted to intensive care with severe hypokalemia (1.5 mmol/L on admission). Thirty-six hours after correction of the hypokalemia, circulatory arrest followed ventricular fibrillation. Her potassium level at that time was 5.8 mmol/L. Outcome was favorable after it returned to normal. DISCUSSION Because its pathogenesis remains debatable, the hypokalemia following hydroxychloroquine poisoning must be corrected with care, even when severe. This correction is difficult, and extracellular transfer of the excess potassium after elimination of the toxin exposes the patient to the risk of ventricular arrhythmia.Resume Introduction L’hydroxychloroquine est, comme la chloroquine, responsable d’un effet stabilisant de membrane et d’une hypokaliemie correlee a la gravite de l’intoxication. La correction de cette hypokaliemie peut exposer au risque d’arythmie ventriculaire. Observation Il s’agit, chez une patiente de 19 ans, d’une intoxication par 6 grammes d’hydroxychloroquine a l’origine d’une hypokaliemie profonde (1,5 mmol/L a l’admission en reanimation). Trente-six heures apres la correction de cette hypokaliemie est survenu un arret circulatoire par fibrillation ventriculaire. La kaliemie etait alors a 5,8 mmol/L. L’evolution a ete favorable apres sa correction. Commentaires En raison d’une pathogenie incertaine, la correction d’une hypokaliemie, meme profonde, apres intoxication par hydroxychloroquine doit etre prudente. Elle est difficile et expose, apres elimination du toxique, au risque d’arythmie ventriculaire lors du transfert extracellulaire de l’exces de potassium apporte.

Blood concentrations are better predictors of chioroquine poisoning severity than plasma concentrations: a prospective study with modeling of the concentration/effect relationships

Introduction. Chloroquine causes rare but life-threatening toxicity. The prognostic value of plasma chloroquine concentrations in acute poisonings remains poorly investigated. We investigated the hypothesis that blood chloroquine concentrations better predicted chloroquine poisoning severity than plasma concentrations. Methods. A prospective study of consecutive chloroquine poisonings admitted to an intensive care unit from 2003 to 2007 was performed with simultaneous measurements of blood and plasma chloroquine (chloroquine and desethylchloroquine) concentrations. A population pharmacokinetic–pharmacodynamic model described epinephrine infusion rate, our surrogate marker of cardiovascular toxicity, as function of blood or plasma chloroquine concentrations. Results. Forty-four patients [29F/15M, 33 years (25–41), median (25–75th percentile), 34% with cardiac arrest] were included. Management included mechanical ventilation (80%), 8.4% sodium bicarbonate (66%), epinephrine [73%, maximal rate: 2.8 mg/h (0.8–5.0)], and extracorporeal life support (16%). Seven patients died. Blood [6.7 mg/L (4.0–13.0)] and plasma [1.5 mg/L (1.2–2.9)] chloroquine concentrations were weakly, although significantly correlated (r = 0.66, p < 0.0001, Spearman test). Admission chloroquine concentrations correlated with the reported ingested dose (r = 0.70 for blood vs. 0.48 for plasma), QRS duration (r = 0.82 vs. 0.64), lactate concentrations (r = 0.63 vs. 0.47), and epinephrine infusion rates (r = 0.70 vs. 0.62). Chloroquine concentrations differed significantly between patients with and without cardiac arrest (p = 0.0002 for blood vs. 0.02 for plasma). A one-compartment pharmacokinetic (PK) model adequately described blood chloroquine concentrations. An effect compartment linked to the blood compartment adequately described plasma chloroquine concentrations. Using a sigmoidal Emax pharmacodynamic (PD) model, epinephrine infusion rate was better predicted with blood than plasma concentrations (p < 0.01), suggesting that time-course of blood concentrations is a better prognostic value than plasma concentrations. Conclusion. Immediate and serial measurements of blood chloroquine concentrations are better than plasma for predicting cardiovascular severity of chloroquine poisonings.

Difficulties in assessing cytomegalovirus-associated gastric perforation in an HIV-infected patient

BackgroundActive Cytomegalovirus (CMV) infection is a common complication in advanced symptomatic Human Immunodeficiency Virus (HIV) infection. CMV-induced intestinal perforations are hard to diagnose and may be observed throughout the gastrointestinal tract. Isolated stomach perforation is exceptional.Case presentationA 47-year-old man was admitted to our intensive care unit with multiorgan failure. Gastrointestinal endoscopic examination showed erythematous gastritis but normal duodenum and colon. CMV blood culture was positive. Histologic examination of a gastric biopsy showed inflammatory infiltrate and immunostaining typical intranuclear CMV inclusion bodies. Concomitant abdominal CT scan disclosed large peripancreatic hypodensities without pneumoperitoneum. The patient died despite supportive therapies and ganciclovir infusion. Postmortem examination showed a 4-cm gastric perforation adhering to the transverse colon and liver, with a thick necrotic inflammatory coating around the pancreas. The whole GI tract, except the stomach, was normal. As other causes, especially Helicobacter pylori infection could be ruled out, a causal relationship between CMV and gastric disease was assumed.ConclusionCMV may be responsible for gastric perforations, with difficulties in assessing the diagnosis. Early diagnosis based on cautious endoscopy and histopathologic examination is needed to make a favorable outcome possible.

Envenomation by the invasive Pterois volitans species (lionfish) in the French West Indies - a two-year prospective study in Martinique.

Abstract Context: The invasion of the lionfish (Pterois volitans) in the French West Indies represents one of the most important marine invasions by alien species in history. Since its first recognition in Martinique in February 2011, the lionfish presence has strongly progressed, resulting in increasing envenomation cases. Our objective was to report features of lionfish envenomation and outcome. Methods: A prospective study conducted at the Martinique University Hospital by the emergency departments, general practitioners, and the pre-hospital emergency ambulance service included all the patients referred from November 2011 to February 2014 for one or several stings by lionfish, as strongly suggested by the fish description and the association with marked local pain and edema. Recommended management included immersion of the affected body part in hot water at 35–40 °C for 60 min, analgesics, tetanus toxoid, and antibiotics. Results: 117 patients [98M/19F; age: 42 ± 14 years [mean ± SD]; with significant past morbidities (16%)] were included. Envenomation resulted in marked pain and local edema (100%), paresthesia (90%), abdominal cramps (62%), extensive edema (53%), tachycardia (34%), skin rash (32%), gastrointestinal disorders (28%), fainting (27%), transient weakness (24%), hypertension (21%), hypotension (18%), hyperthermia (9%), bradycardia (3%), hypophosphatemia (12%), elevated aspartate aminotransferase (AST) (10%), and thrombocytopenia (3%). The sting was complicated by local infection (18%) including skin abscess (5%), cellulitis (3%), skin necrosis (3%), and septic arthritis (2%). 26 patients (22%) were hospitalized requiring surgery (8%). Lionfish stings were single (81%) or multiple (19%). Localization was preferentially at one upper (67%) or lower limb (32%). All patients actually improved. Based on multivariate analyses, pain duration > 24 h was significantly associated with skin eruption (p = 0.001) and muscle cramps (p = 0.0002). Local infectious complications occurred more frequently in patients presenting multiple stings (p = 0.008). Immersion in hot water (44%, performed less than 3 h after the sting in 36% of the cases) significantly reduced pain duration (p = 0.02) and local infection (p = 0.02). Conclusion: Lionfish represents a major health threat in Martinique with increasing envenomation and significant morbidities. Outcome is favorable if promptly managed, with possible reduction in pain duration and local infections with the rapid immersion of the stung body part in hot water. Our data encourage the authorities to develop investigations on the exact extent of the lionfish invasion and set up a regional taskforce to inform the ecosystem users and register all lionfish-attributed incidents.

Preclinical evaluation of the neutralizing ability of a monospecific antivenom for the treatment of envenomings by Bothrops lanceolatus in Martinique

ABSTRACT Bothrops lanceolatus is an endemic viperid species in the Lesser Caribbean island of Martinique. Envenomings by this species are characterized by local and systemic effects, among which the development of thrombosis in various organs is the most severe complication. An experimental toxicological characterization of this venom was performed using in vivo mouse tests and various in vitro assays. The venom induced lethal, local and systemic hemorrhagic, edema‐forming, myotoxic, thrombocytopenic, proteinase and phospholipase A2 activities. The preclinical efficacy of a batch of monospecific Bothrofav® antivenom currently in use in Martinique was assessed. The antivenom was highly effective in the neutralization of all activities tested, in agreement with its described clinical efficacy. This batch of antivenom showed a higher preclinical efficacy as compared to a previous batch used in the past. HIGHLIGHTSThe toxicological profile of the venom of Bothrops lanceolatus from Martinique was studied.Venom induced lethal, hemorrhagic, myotoxic, edema‐forming, and thrombocytopenic effects.The monospecific antivenom Bothrofav® was effective in the neutralization of these effects.This batch of antivenom showed a higher potency than another batch previously used.

Influence of intra-abdominal pressure on the specificity of pulse pressure variations to predict fluid responsiveness.

BACKGROUND The positive predictive value of pulse pressure variations (&Dgr;PP) to discriminate patients who should respond to volume expansion (VE) may be altered in mechanically ventilated patients. Our goal was to determine whether intra-abdominal pressure (IAP) measurements could discriminate patients with true-positive &Dgr;PP values versus patients with false-positive &Dgr;PP values. METHODS We designed a prospective pathophysiologic study in a mixed intensive care unit of a university hospital. Sixteen mechanically ventilated patients with hypotension (SAP, <90 mm Hg) and with &Dgr;PP of 13% or more were included. Cardiac output was assessed using Doppler echocardiography before and after VE; IAP was measured using the bladder pressure method. Patients were classified into two groups according to their response to a standardized VE (500 mL of NaCl 0.9%): responders (≥15% increase in cardiac output) and nonresponders. RESULTS Nine patients (57%) were responders, and seven patients (43%) were nonresponders. Before VE, IAP was statistically higher in nonresponders (15 [11–22] mm Hg vs. 9 [6.5–11] mm Hg; p = 0.008). The area under the curve of the receiver operating characteristic curve was 0.9 ± 0.08. In patients with &Dgr;PP of 13% or more, an IAP cutoff value of 10.5 mm Hg discriminated between responders and nonresponders with a sensitivity of 100% (59–100%) and a specificity of 78% (40–97%). CONCLUSION An increase in IAP of more than 10.5 mm Hg can decrease the positive predictive value of &Dgr;PP. Hence, in patients prone to present abnormal IAP values, IAP should be measured before performing VE directed by the &Dgr;PP marker. LEVEL OF EVIDENCE Diagnostic study, level II.

Incidence and Consequences of Near-Drowning–Related Pneumonia—A Descriptive Series from Martinique, French West Indies

Drowning represents one major cause of accidental death. Near-drowning patients are exposed to aspiration that may result in pneumonia with life-threatening consequences. We designed this descriptive study to investigate the frequency, nature, and consequences of post-drowning pneumonia. One hundred and forty-four near-drowning patients (33 children and 111 adults) admitted during four years to the University Hospital of Martinique, French Indies, were included. Patients presented pre-hospital cardiac arrest (41%) and exhibited acute respiratory failure (54%), cardiovascular failure (27%), and lactic acidosis (75%) on admission. Empirical antibiotics, as decided by the physicians in charge, were administered in 85 patients (59%). Post-drowning early onset bacterial pneumonia was diagnosed as “possible” in 13 patients (9%) and “confirmed” in 22 patients (15%). Tracheal aspiration revealed the presence of polymorphous pharyngeal flora (59%) or one predominant bacteria species (41%) including Enterobacter aerogenes, Enterobacter cloacae, Staphylococcus aureus, Pseudomonas aeruginosa, Aeromonas hydrophilia, and Morganella morgani. Despite adequate supportive care, drowning resulted in 45 fatalities (31%). Early onset bacterial aspiration pneumonia (either possible or confirmed) did not significantly influence the risk of death. In conclusion, near-drowning–related bacterial aspiration pneumonia seems rare and does not influence the mortality rate. There is still a need for practice standardization to improve diagnosis of post-drowning pneumonia and near-drowning patient management.