David Vandroux

Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad.

BACKGROUNDnFew national recommendations exist on management of patients returning from abroad and all focus on hospitalized patients. Our purpose was to compare, in an intensive care unit (ICU), the admission prevalence and acquisition of multidrug-resistant (MDR) bacteria carriage in patients with (Abroad) or without (Local) a recent stay abroad, and then identify the risk factors in Abroad patients.nnnMETHODSnIn this retrospective study, we reviewed charts of all the patients hospitalized in the ICU unit from January 2011 through July 2013 with hygiene samplings performed. We identified all patients who had stayed abroad (Abroad) within 6 months prior to ICU admission.nnnRESULTSnOf 1,842 ICU patients, 129 (7%) Abroad patients were reported. In the Abroad group, the rate of MDR strain carriage was higher at admission (33% vs 6.7%, p < 0.001) and also more often diagnosed during the ICU stay (acquisition rate: 17% vs 5.2%, p < 0.001) than in Local patients. Risk factors associated with MDR bacteria carriage at admission in Abroad patients were diabetes mellitus [odds ratio (OR) 5.1 (1.7-14.8), p = 0.003] and hospitalization abroad with antibiotic treatment [OR 10.7 (4.2-27.3), p < 0.001]. Hospitalization abroad without antibiotic treatment was not identified as a risk factor.nnnCONCLUSIONSnThe main factor associated with MDR bacteria carriage after a stay abroad seems to be a hospitalization abroad only in case of antibiotic treatment abroad. Screening and isolation of Abroad patients should be recommended, even in case of a first negative screening.

Influenza season in Réunion dominated by influenza B virus circulation associated with numerous cases of severe disease, France, 2014

The 2014 seasonal influenza in Réunion, a French overseas territory in the southern hemisphere, was dominated by influenza B. Resulting morbidity impacted public health. Relative to the total number of all-cause consultations over the whole season, the rate of acute respiratory infection (ARI) consultations was 6.5%. Severe disease occurred in 32 laboratory-confirmed influenza cases (31.7 per 100,000 ARI consultations), 16 with influenza B. The observed disease dynamics could present a potential scenario for the next European influenza season.

Prevalence and Risk Factors of Stress Cardiomyopathy After Convulsive Status Epilepticus in ICU Patients.

Objective:Although stress cardiomyopathy has been described in association with epilepsy, its frequency in patients with convulsive status epilepticus remains unknown. Accordingly, we sought to determine the prevalence and risk factors of stress cardiomyopathy in patients admitted to the ICU for convulsive status epilepticus. Design:Prospective, descriptive, single-center study. Setting:Medical-surgical ICU of a teaching hospital. Patients:Thirty-two consecutive ventilated patients (21 men; age, 50 ± 18 yr; Simplified Acute Physiology Score II, 53 ± 15; Sequential Organ Failure Assessment, 6 ± 2) hospitalized in the ICU for convulsive status epilepticus. Interventions:None. Measurements and Main Results:Hemodynamic parameters, transthoracic echocardiography, biological data, and electrocardiogram were obtained serially on ICU admission (H0), and after 6, 12, 24, and 48 hours of hospitalization (H6, H12, H24, and H48). Stress cardiomyopathy was defined as a 20% decrease in left ventricular ejection fraction between H0 or H6 and H48. Stress cardiomyopathy was diagnosed in 18 patients (56%; 95% CI, 38–74%). Mean left ventricular ejection fraction, left ventricular stroke index and cardiac index were initially (at H0 or H6 according to lowest individual values) significantly reduced in stress cardiomyopathy patients (45 ± 14% vs 61 ± 6%, p < 0.001; 24 ± 8 vs 28 ± 8 mL/m2, p < 0.05; 2.3 ± 0.7 vs 3.0 ± 0.8 L/min/m2, p < 0.05, respectively) and increased secondarily to reach similar mean values than those observed in patients without transient left ventricular dysfunction at H24. Dobutamine was more frequently used in patients with stress cardiomyopathy. Mean lactate level was increased and significantly higher in stress cardiomyopathy patients at H0 and H6, whereas mean central venous oxygen saturation was preserved but significantly lower in this group. Only three patients with stress cardiomyopathy had left ventricular regional wall motion abnormalities but normal coronary angiography. Risk factors of stress cardiomyopathy were age and Simplified Acute Physiology Score II. Conclusions:These results suggest that stress cardiomyopathy is common in patients admitted to the ICU for convulsive status epilepticus. Accordingly, these patients should be screened for stress cardiomyopathy and monitored if they present with hemodynamic compromise.

Stress (Tako-tsubo) cardiomyopathy in critically-ill patients

Background: Stress cardiomyopathy (SC) is a transient ventricular dysfunction rarely described in the critical care setting. Objective: To evaluate the mechanisms, incidence, treatment and prognosis of SC. Method: This is a retrospective observational study of every critically-ill patient admitted to the ICU over a period of two years. Results: Among 1314 patients admitted in the ICU, 20 patients (1.5%) were diagnosed with SC. A total of 249 patients experienced cardiogenic shock, whereas 8% were suffering from SC. SC was suspected because of hemodynamic impairment (80% of cases), ECG modifications (15%) and/or dyspnea (15%). SC was apical (typical Tako-tsubo) in 90% and atypical in 10% of cases. Several mechanisms or conditions may explain the occurrence of SC and are may be combined: catecholamine toxicity (45%), psychological stress, seizures or neurological impairment (35%), non-epicardial coronary ischemia (20%) and left ventricular outflow track (LVOT) obstruction (10%). SC could have indirectly caused death by worsening heart failure in three patients and arrhythmias were seen in 40% of patients. SAPS2, renal impairment, malnutrition, norepinephrine infusion and thrombocytopenia were associated with death in the univariate analysis. Catecholamines were required in 85% and intra-aortic balloon pump in 20% of patients. Conclusions: SC is a rare reversible cardiac impairment in the critically-ill patient that can induce arrhythmias and cardiogenic shock. The likely mechanisms are combined: catecholamine toxicity, stress or neurological involvement and less frequently ischemia or LVOT obstruction.

Assessment of the National French recommendations regarding the dosing regimen of 8 mg/kg of gentamicin in patients hospitalised in intensive care units

INTRODUCTIONnTo assess the French National Agency for Medicines and Health Products Safety (ANSM) guidelines concerning the peak plasma concentration (Cmax) of gentamicin when using a loading dose of 8mg/kg administered in patients hospitalised in the intensive care unit (ICU).nnnPATIENTS AND METHODSnA prospective observational cohort study conducted in one ICU.nnnRESULTSnDuring the study period, 34 patients with a median simplified acute physiology score 2 of 54 [44-70] received a median dose of 8 [7.9-8.1] mg/kg of gentamicin. The median Cmax was 17.5 [15.4-20.7] mg/L and no patient had a Cmax>30mg/L. Twenty-four of 34 patients (71%) had a Cmax>16mg/L. Following multivariate analysis, the only factor associated with Cmax<16mg/L was a positive fluid balance 24hours before gentamicin administration (per 1000mL increment) (OR: 0.37, 95% CI: 0.18-0.77, P=0.008).nnnCONCLUSIONSnThese results suggest that a Cmax>30mg/L [which corresponds to approximately 8 times the minimal inhibiting concentrations (MIC) breakpoints for Pseudomonas aeruginosa and Enterobacteriaceae with intermediate sensitivity] of gentamicin as recommended by ANSM guidelines seems impossible to obtain with a loading dose of 8mg/kg in the ICU. A loading dose of 8mg/kg should probably not be used in the empiric antibiotic treatment of infection due to non-fermenting Gram-negative bacilli and Enterobacteriaceae with intermediate sensitivity whose MIC breakpoint is 4mg/L. A Cmax>16mg/L was not reached in almost 30% of patients, particularly in the group with a positive fluid balance who require higher doses than currently recommended.

Delayed Diagnosis of High Drug-Resistant Microorganisms Carriage in Repatriated Patients: Three Cases in a French Intensive Care Unit

We report three cases of high drug-resistant microorganisms (HDRMO) carriage by patients repatriated from a foreign country. National recommendations suggest systematic screening and contact isolation pending results of admission screening of all patients recently hospitalized abroad. HDRMO carriage (carbapenem-resistant Acinetobacter baumanii and carbapenemase-producing Enterobacteriaceae) was not isolated on admission screening swabs, but later between 3 and 8u2009days after admission. In absence of cross-transmission, two hypotheses seem possible: a false-negative test on admission, or a late onset favored by antibiotic pressure. Prolonged isolation may be discussed even in case of negative screening on admission from high-risk patients.

Right over left ventricular end-diastolic area relevance to predict hemodynamic intolerance of high-frequency oscillatory ventilation in patients with severe ARDS

BackgroundHigh-frequency oscillatory ventilation (HFOV) does not improve the prognosis of ARDS patients despite an improvement in oxygenation. This paradox may partly be explained by HFOV hemodynamic side-effects on right ventricular function. Our goal was to study the link between HFOV and hemodynamic effects and to test if the pre-HFOV right over left ventricular end-diastolic area (RVEDA/LVEDA) ratio, as a simple parameter of afterload-related RV dysfunction, could be used to predict HFOV hemodynamic intolerance in patients with severe ARDS.MethodsTwenty-four patients were studied just before and within 3xa0h of HFOV using transthoracic echocardiography and transpulmonary thermodilution.ResultsBefore HFOV, the mean PaO2/FiO2 ratio was 89xa0±xa023. The number of patients with a RVEDA/LVEDA ratioxa0>0.6 significantly increased after HFOV [11 (46xa0%) vs. 17 (71xa0%)]. Although HFOV did not significantly decrease the arterial pressure (systolic, diastolic, mean and pulse pressure), it significantly decreased the cardiac index (CI) by 13xa0±xa018xa0% and significantly increased the RVEDA/LVEDA ratio by 14xa0±xa011xa0%. A significant correlation was observed between pre-HFOV RVEDA/LVEDA ratio and CI diminution after HFOV (rxa0=xa00.78; pxa0<xa00.0001). A RVEDA/LVEDA ratio superior to 0.6 resulted in a CI decreasexa0>15xa0% during HFOV with a sensitivity of 80xa0% (95xa0% confidence interval 44–98xa0%) and a specificity of 79xa0% (confidence interval 49–95xa0%).ConclusionThe RVEDA/LVEDA ratio measured just before HFOV predicts the hemodynamic intolerance of this technique in patients with severe ARDS. A high ratio under CMV raises questions about the use of HFOV in such patients.Trial registration: ClinicalTrials.gov: NCT01167621

Beneficial effects of intravenous beta-blockers in Tako-Tsubo syndrome with dynamic left ventricular outflow tract obstruction and severe haemodynamic impairment

Article history: Received 22 September 2014 Accepted 27 September 2014 Available online 5 October 2014 tion but with negative T waves in V1 to V5. There was no recent history of psychological stress. Physical examination revealed bibasilar crackles and a lowblood pressure (80/45mmHg). Shewas treatedwith heparin, aspirin, and ticagrelor for a suspected acute coronary syndrome ruled out by cardiac catheterizationwhich revealed a severeMRwith a typical apical ballooning of the left ventricle (Fig. 1). Treatment consisted of dobutamine (10 mcg/kg/min), non-invasive ventilation, intra-aortic balloon pump (IABP), diuretics. Upon admission in our ICU, patient

Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography: A Comparative Study

Background To assess the agreement between transpulmonary thermodilution (TPT) and critical care echocardiography (CCE) in ventilated patients with septic shock. Methods Ventilated patients in sinus rhythm requiring advanced hemodynamic assessment for septic shock were included in this prospective multicenter descriptive study. Patients were assessed successively using TPT and CCE in random order. Data were interpreted independently at bedside by two investigators who proposed therapeutic changes on the basis of predefined algorithms. TPT and CCE hemodynamic assessments were reviewed offline by two independent experts who identified potential sources of discrepant results by consensus. Lactate clearance and outcome were studied. Results A total of 137 patients were studied (71 men; age, 61 ± 15 years; Simplified Acute Physiologic Score, 58 ± 18; Sequential Organ Failure Assessment, 10 ± 3). TPT and CCE interpretations at bedside were concordant in 87/132 patients (66%) without acute cor pulmonale (ACP), resulting in a moderate agreement (kappa, 0.48; 95% CI, 0.37‐0.60). Experts’ adjudications were concordant in 100/129 patients without ACP (77.5%), resulting in a good intertechnique agreement (kappa, 0.66; 95% CI, 0.55‐0.77). In addition to ACP (n = 8), CCE depicted a potential source of TPT inaccuracy in 8/29 patients (28%). Lactate clearance at H6 was similar irrespective of the concordance of online interpretations of TPT and CCE (55/84 [65%] vs 32/45 [71%], P = .55). ICU and day 28 mortality rates were similar between patients with concordant and discordant interpretations (29/87 [36%] vs 13/45 [29%], P = .60; and 31/87 [36%] vs 16/45 [36%], P = .99, respectively). Conclusions Agreement between TPT and CCE was moderate when interpreted at bedside and good when adjudicated offline by experts, but without impact on lactate clearance and mortality.

Prognosis of patients presenting extreme acidosis (pH <7) on admission to intensive care unit.

PURPOSEnThe purpose was to determine prognosis of patients presenting extreme acidosis (pH <7) on admission to the intensive care unit (ICU) and to identify mortality risk factors.nnnMATERIALS AND METHODSnWe retrospectively analyzed all patients who presented with extreme acidosis within 24 hours of admission to a polyvalent ICU in a university hospital between January 2011 and July 2013. Multivariate analysis and survival analysis were used.nnnRESULTSnAmong the 2156 patients admitted, 77 patients (3.6%) presented extreme acidosis. Thirty (39%) patients suffered cardiac arrest before admission. Although the mortality rate predicted by severity score was 93.6%, death occurred in 52 cases (67.5%) in a median delay of 13 (5-27) hours. Mortality rate depended on reason for admission, varying between 22% for cases linked to diabetes mellitus and 100% for cases of mesenteric infarction (P = .002), cardiac arrest before admission (P < .001), type of lactic acidosis (P = .007), high Simplified Acute Physiology Score II (P = .008), and low serum creatinine (P = .012).nnnCONCLUSIONSnPatients with extreme acidosis on admission to ICU have a less severe than expected prognosis. Whereas mortality is almost 100% in cases of cardiac arrest before admission, mortality is much lower in the absence of cardiac arrest before admission, which justifies aggressive ICU therapies.