Guillaume Dufour

Preoperative Statin Treatment Is Associated With Reduced Postoperative Mortality After Isolated Cardiac Valve Surgery in High-Risk Patients

OBJECTIVE The aim of the present study was to assess the influence of preoperative statin therapy on postoperative mortality in high-risk patients after isolated valve surgery. DESIGN An observational cohort study. SETTING A 1,200-bed university hospital. PARTICIPANTS All consecutive patients undergoing isolated nonemergent valve surgery with cardiopulmonary bypass between November 2005 and December 2007 were included. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS During the period, 772 consecutive patients underwent nonemergent isolated valve surgery. Among them, 430 were high cardiovascular risk (defined by patients with 2 or more cardiovascular risk factors). In the high-risk cardiovascular patients, statin pretreatment was administered in 222 patients (52%). In multivariate analysis, after adjustment with a propensity score analysis, preoperative statin therapy was associated with a significant reduction of postoperative mortality in patients with high risk (odds ratio = 0.41; 95% confidence interval, 0.17-0.97; p = 0.04). Low left ventricular ejection fraction and elevated pulmonary artery pressure also were independently associated with increased postoperative mortality. By contrast, in the low-risk patient group, few patients received preoperative statin therapy (7%). CONCLUSIONS This study suggests that preoperative statin therapy may have a potential beneficial effect on postoperative mortality after isolated cardiac valve surgery in high-risk cardiovascular patients.

Abdominal Compartment Syndrome Due to Extracorporeal Membrane Oxygenation in Adults

Extracorporeal membrane oxygenation (ECMO) improves the outcome of refractory cardiogenic shock. Few studies in adult populations have specifically addressed the complications of ECMO. Abdominal compartment syndrome (ACS) has been previously described in the pediatric literature, but it has never been directly attributed to ECMO alone. The authors describe two cases of ACS directly induced by venoarterial ECMO. In one case, decompressive laparotomy restored an adequate hemodynamic status. The authors hypothesize that ECMO contributed to ACS by inducing massive fluid overload and subsequent tense ascites. In conclusion, when ECMO dysfunction or hemodynamic impairment occurs, ACS should be considered and a decompressive laparotomy should be performed.

Diagnosis and management of the postoperative surgical and medical complications of bariatric surgery

Perioperative complications following bariatric surgery (BS) have been poorly analysed and their management is not clearly assessed. The associated frequency of ICU admission is difficult to estimate. Among surgical complications, digestive perforations are the most frequent. The most common postoperative complications of sleeve gastrectomy are fistulas, but bleeding on the stapling line is also commonly reported. Complication rates are higher after Roux-en-Y gastric bypass, mainly due to anastomotic leaks. Medical complications are mainly thromboembolic or respiratory complications. All these surgical and medical complications are not easily detected; clinical signs can be atypical or insidious, often resulting in delayed management. Respiratory signs can be predominant and lead erroneously to pulmonary or thromboembolic diseases. Diagnostic criteria are based on minor clinical signs, tachycardia being probably the most frequent one. Lately, complications are revealed by haemodynamic instability, respiratory failure or renal dysfunction and radiographic findings. Management decision according to these abnormal signs is based on a combined multidisciplanary approach including surgical and/or endoscopic procedures and medical care, depending on the nature and severity of the surgical complication. Medical management is based on supportive ICU care of organ dysfunctions, curative anticoagulation if required, nutritional support, and appropriate anti-infective therapy. Pharmacological data are limited in morbidly obese patients and the appropriate doses are debated, especially for anti-infective agents. Complicated BS cases have a poor outcome, probably largely related to delayed diagnosis and reoperation.

Echocardiography to predict tolerance to negative fluid balance in acute respiratory distress syndrome/acute lung injury

PURPOSE In acute respiratory distress syndrome (ARDS) and acute lung injury (ALI), a conservative fluid management strategy improves lung function but could jeopardize extrapulmonary organ perfusion. The objective was to evaluate the diagnostic accuracy of echocardiography to predict tolerance of negative fluid balance (NFB) in patients with ARDS/ALI. MATERIALS AND METHODS A prospective and observational study in an adult intensive care unit of a university hospital was conducted. All hemodynamically stable patients with ARDS/ALI were included. Echocardiography was performed before NFB and again after 24 hours. Tolerance of NFB was evaluated by the presence of hypotension, acute kidney injury, or need for fluid expansion. The 2 patient groups (tolerating and not tolerating NFB) were compared. RESULTS Forty-five patients were included. Median age (Q1-Q3) was 58 (52-66) years, and the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen was 205 (163-258) mm Hg. Negative fluid balance was 1950 (1200-2200) mL within 24 hours in the tolerant group. Complications of NFB were observed in 35% cases. After univariate and multivariate logistic regression analyzes, 2 criteria was independently associates with poor tolerance: mitral inflow E wave to early diastolic mitral annulus velocities ratio (E/Ea ratio; odds ratio, 2.02 [1.02-4.02]; P = .04) and weight gain (odds ratio, 1.2 [1.03-1.4]; P = .02). The area under receiver operating characteristic curves was 0.74 for E/Ea and 0.77 for weight gain. CONCLUSIONS The ratio of E/Ea accurately predicted tolerance of NFB in patients with ARDS/ALI.

Does IV Iron Induce Plasma Oxidative Stress in Critically Ill Patients? A Comparison With Healthy Volunteers.

Objective:To compare the oxidative stress induced by IV iron infusion in critically ill patients and in healthy volunteers. Design:Multicenter, interventional study. Setting:Two ICUs and one clinical research center. Subjects:Anemic critically ill patients treated with IV iron and healthy volunteers. Interventions:IV infusion of 100 mg of iron sucrose. Measurements and Main Results:Thirty-eight anemic patients (hemoglobin, median [interquartile range] = 8.4 g/dL [7.7–9.2]) (men, 25 [66%]; aged 68 yr [48–77]; Simplified Acute Physiology Score II, 48.5 [39–59]) and 39 healthy volunteers (men, 18 [46%]; aged 42.1 yr [29–50]) were included. Blood samples were drawn before (H0) and 2, 6, and 24 hours (H2, H6, and H24) after a 60-minute iron infusion for the determination of nontransferrin bound iron, markers of lipid peroxidation—8&agr;-isoprostanes, protein oxidation—advanced oxidized protein product, and glutathione reduced/oxidized. Iron infusion had no effect on hemodynamic parameter in patients and volunteers. At baseline, patients had much higher interleukin-6, C-reactive protein, and hepcidin levels. 8&agr;-isoprostanes was also higher in patients at baseline (8.5 pmol/L [6.5–12.9] vs 4.6 pmol/L [3.5–5.5]), but the area under the curve above baseline from H0 to H6 was not different (p = 0.38). Neither was it for advanced oxidized protein product and nontransferrin bound iron. The area under the curve above baseline from H0 to H6 (glutathione reduced/oxidized) was lower in volunteers (p = 0.009). Eight patients had a second set of dosages (after the fourth iron infusion), showing higher increase in 8&agr;-isoprostanes. Conclusions:In our observation, IV iron infusion does not induce more nontransferrin bound iron, lipid, or protein oxidation in patients compared with volunteers, despite higher inflammation, oxidative stress, and hepcidin levels and lower antioxidant at baseline. In contrary, iron induces a greater decrease in antioxidant, compatible with higher oxidative stress in volunteers than in critically ill patients.

Aortic rupture due to pneumococcal infection in aortoiliac stents

We report a rare case of pneumococcal aortitis secondary to endovascular bare-metal stent infection. The patient was a 70-year-old man presenting with back pain 1 year after aortoiliac implantation of bare-metal kissing stents. Final diagnosis was microbial aortitis due to Streptococcus pneumoniae involving the stents that resulted in a contained aortic rupture requiring urgent surgical treatment. Emergency extra-anatomic revascularization, excision of the infected tissues, and appropriate antibiotic therapy led to a favorable outcome. A high index of suspicion is required in such a situation because the mortality rate is very high in the absence of appropriate treatment.