Hakim Haouache

Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial.

CONTEXT Use of a chlorhexidine gluconate-impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections (CRIs). Changing catheter dressings every 3 days may be more frequent than necessary. OBJECTIVE To assess superiority of CHGIS dressings regarding the rate of major CRIs (clinical sepsis with or without bloodstream infection) and noninferiority (less than 3% colonization-rate increase) of 7-day vs 3-day dressing changes. DESIGN, SETTING, AND PATIENTS Assessor-blind, 2 x 2 factorial, randomized controlled trial conducted from December 2006 through June 2008 and recruiting patients from 7 intensive care units in 3 university and 2 general hospitals in France. Patients were adults (>18 years) expected to require an arterial catheter, central-vein catheter, or both inserted for 48 hours or longer. INTERVENTIONS Use of CHGIS vs standard dressings (controls). Scheduled change of unsoiled adherent dressings every 3 vs every 7 days, with immediate change of any soiled or leaking dressings. MAIN OUTCOME MEASURES Major CRIs for comparison of CHGIS vs control dressings; colonization rate for comparison of 3- vs 7-day dressing changes. RESULTS Of 2095 eligible patients, 1636 (3778 catheters, 28,931 catheter-days) could be evaluated. The median duration of catheter insertion was 6 (interquartile range [IQR], 4-10) days. There was no interaction between the interventions. Use of CHGIS dressings decreased the rates of major CRIs (10/1953 [0.5%], 0.6 per 1000 catheter-days vs 19/1825 [1.1%], 1.4 per 1000 catheter-days; hazard ratio [HR], 0.39 [95% confidence interval {CI}, 0.17-0.93]; P = .03) and catheter-related bloodstream infections (6/1953 catheters, 0.40 per 1000 catheter-days vs 17/1825 catheters, 1.3 per 1000 catheter-days; HR, 0.24 [95% CI, 0.09-0.65]). Use of CHGIS dressings was not associated with greater resistance of bacteria in skin samples at catheter removal. Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1000 catheters). Use of CHGIS dressings prevented 1 major CRI per 117 catheters. Catheter colonization rates were 142 of 1657 catheters (7.8%) in the 3-day group (10.4 per 1000 catheter-days) and 168 of 1828 catheters (8.6%) in the 7-day group (11.0 per 1000 catheter-days), a mean absolute difference of 0.8% (95% CI, -1.78% to 2.15%) (HR, 0.99; 95% CI, 0.77-1.28), indicating noninferiority of 7-day changes. The median number of dressing changes per catheter was 4 (IQR, 3-6) in the 3-day group and 3 (IQR, 2-5) in the 7-day group (P < .001). CONCLUSIONS Use of CHGIS dressings with intravascular catheters in the intensive care unit reduced risk of infection even when background infection rates were low. Reducing the frequency of changing unsoiled adherent dressings from every 3 days to every 7 days modestly reduces the total number of dressing changes and appears safe. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00417235.

Outcomes in severe sepsis and patients with septic shock: pathogen species and infection sites are not associated with mortality.

Objectives:We evaluated the respective influence of the causative pathogen and infection site on hospital mortality from severe sepsis related to community-, hospital-, and intensive care unit-acquired infections. Design:We used a prospective observational cohort 10-yr database. We built a subdistribution hazards model with corrections for competing risks and adjustment for potential confounders including early appropriate antimicrobial therapy. Setting:Twelve intensive care units. Patients:We included 4,006 first episodes of acquisition-site-specific severe sepsis in 3,588 patients. Inteventions:None. Measurements and Main Results:We included 1562 community-acquired, 1432 hospital-acquired, and 1012 intensive care unit-acquired episodes of severe sepsis. After adjustment, we found no independent associations of the causative organism, multidrug resistance of the causative organism, infection site, or presence of bacteremia with mortality. Early appropriate antimicrobial therapy was consistently associated with better survival in the community-acquired (0.64 [0.51–0.8], p = .0001), hospital-acquired (0.72 [0.58–0.88], p = .0011), and intensive care unit-acquired (0.79 [0.64–0.97], p = .0272) groups. Conclusion:The infectious process may not exert as strong a prognostic effect when severity, organ dysfunction and, above all, appropriateness of early antimicrobials are taken into account. Our findings emphasize the importance of developing valid recommendations for early antimicrobial therapy.

Infectious risk associated with arterial catheters compared with central venous catheters

Background:Scheduled replacement of central venous catheters and, by extension, arterial catheters, is not recommended because the daily risk of catheter-related infection is considered constant over time after the first catheter days. Arterial catheters are considered at lower risk for catheter-related infection than central venous catheters in the absence of conclusive evidence. Objectives:To compare the daily risk and risk factors for colonization and catheter-related infection between arterial catheters and central venous catheters. Methods:We used data from a trial of seven intensive care units evaluating different dressing change intervals and a chlorhexidine-impregnated sponge. We determined the daily hazard rate and identified risk factors for colonization using a marginal Cox model for clustered data. Results:We included 3532 catheters and 27,541 catheter-days. Colonization rates did not differ between arterial catheters and central venous catheters (7.9% [11.4/1000 catheter-days] and 9.6% [11.1/1000 catheter-days], respectively). Arterial catheter and central venous catheter catheter-related infection rates were 0.68% (1.0/1000 catheter-days) and 0.94% (1.09/1000 catheter-days), respectively. The daily hazard rate for colonization increased steadily over time for arterial catheters (p = .008) but remained stable for central venous catheters. Independent risk factors for arterial catheter colonization were respiratory failure and femoral insertion. Independent risk factors for central venous catheter colonization were trauma or absence of septic shock at intensive care unit admission, femoral or jugular insertion, and absence of antibiotic treatment at central venous catheter insertion. Conclusions:The risks of colonization and catheter-related infection did not differ between arterial catheters and central venous catheters, indicating that arterial catheter use should receive the same precautions as central venous catheter use. The daily risk was constant over time for central venous catheter after the fifth catheter day but increased significantly over time after the seventh day for arterial catheters. Randomized studies are needed to investigate the impact of scheduled arterial catheter replacement. (Crit Care Med 2010; 38:1030–1035)

Immune status and apoptosis activation during brain death.

The present study evaluates the role of the inflammatory status and apoptosis activation in the development of organ dysfunction after brain death using plasma assays and macroarray analysis on skeletal muscle biopsies to look for evidence of remote tissue damage in two intensive care units in France and one in Belgium. As controls, we used patients undergoing hip surgery and healthy volunteers. Causes of brain death in the 85 consecutive patients included in the study were cardiac arrest (n = 29; 34%), stroke (n = 42; 49%, with 38 patients having hemorrhagic stroke), and head injury (n = 14; 17%). Of the 85 patients, 45 donated 117 organs. Plasma endotoxin and cytokine levels indicated a marked systemic inflammatory response in brain-dead patients, which was strongest in the cardiac arrest group. Leukocyte dysfunction, as assessed by cytokines production in response to various stimuli, was noted in a subgroup of patients with brain death after stroke. Interestingly, skeletal muscle biopsies showed no increase in mRNAs for genes related to inflammation, whereas mRNAs for both antiapoptotic and proapoptotic genes were increased, the balance being in favor of apoptosis induction. The increased activation of the proapoptotic caspase 9 was further confirmed by Western blot. In conclusion, the presence of inflammation and apoptosis induction may explain the rapid organ dysfunction seen after brain death. Both abnormalities may play a role in organ dysfunction associated with brain death. However, the level of systemic inflammation or the presence of circulating endotoxin was not associated with lower graft survival.

Serum 1H-NMR Metabolomic Fingerprints of Acute-On-Chronic Liver Failure in Intensive Care Unit Patients with Alcoholic Cirrhosis

Introduction Acute-on-chronic liver failure is characterized by acute deterioration of liver function in patients with compensated or decompensated, but stable, cirrhosis. However, there is no accurate definition of acute-on-chronic liver failure and physicians often use this term to describe different clinical entities. Metabolomics investigates metabolic changes in biological systems and identifies the biomarkers or metabolic profiles. Our study assessed the metabolomic profile of serum using proton nuclear magnetic resonance (1H-NMR) spectroscopy to identify metabolic changes related to acute-on-chronic liver failure. Patients Ninety-three patients with compensated or decompensated cirrhosis (CLF group) but stable liver function and 30 patients with cirrhosis and hospitalized for the management of an acute event who may be responsible of acute-on-chronic liver failure (ACLF group), were fully analyzed. Blood samples were drawn at admission, and sera were separated and stored at –80°C until 1H-NMR spectral analysis. Using orthogonal projection to latent-structure discriminant analyses, various metabolites contribute to the complete separation between these both groups. Results The predictability of the model was 0.73 (Q2 Y) and the explained variance was 0.63 (R2 Y). The main metabolites that had increased signals related to acute-on-chronic liver failure were lactate, pyruvate, ketone bodies, glutamine, phenylalanine, tyrosine, and creatinine. High-density lipids were lower in the ALCF group than in CLF group. Conclusion A serum metabolite fingerprint for acute-on-chronic liver failure, obtained with 1H-NMR, was identified. Metabolomic profiling may aid clinical evaluation of patients with cirrhosis admitted into intensive care units with acute-on-chronic liver failure, and provide new insights into the metabolic processes involved in acute impairment of hepatic function.

Acute Respiratory Distress Syndrome and Risk of AKI among Critically Ill Patients

BACKGROUND AND OBJECTIVES Increasing experimental evidence suggests that acute respiratory distress syndrome (ARDS) may promote AKI. The primary objective of this study was to assess ARDS as a risk factor for AKI in critically ill patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was an observational study on a prospective database fed by 18 intensive care units (ICUs). Patients with ICU stays >24 hours were enrolled over a 14-year period. ARDS was defined using the Berlin criteria and AKI was defined using the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease criteria. Patients with AKI before ARDS onset were excluded. RESULTS This study enrolled 8029 patients, including 1879 patients with ARDS. AKI occurred in 31.3% of patients and was more common in patients with ARDS (44.3% versus 27.4% in patients without ARDS; P<0.001). After adjustment for confounders, both mechanical ventilation without ARDS (odds ratio [OR], 4.34; 95% confidence interval [95% CI], 3.71 to 5.10) and ARDS (OR, 11.01; 95% CI, 6.83 to 17.73) were independently associated with AKI. Hospital mortality was 14.2% (n=1140) and was higher in patients with ARDS (27.9% versus 10.0% in patients without ARDS; P<0.001) and in patients with AKI (27.6% versus 8.1% in those without AKI; P<0.001). AKI was associated with higher mortality in patients with ARDS (42.3% versus 20.2%; P<0.001). CONCLUSIONS ARDS was independently associated with AKI. This study suggests that ARDS should be considered as a risk factor for AKI in critically ill patients.

Influence of early dysnatremia correction on survival of critically ill patients.

ABSTRACT Increasing evidence suggests that dysnatremia at intensive care unit (ICU) admission may predict mortality. Little information is available, however, on the potential effect of dysnatremia correction. This is an observational multicenter cohort study in patients admitted between 2005 and 2012 to 18 French ICUs. Hyponatremia and hypernatremia were defined as serum sodium concentration less than 135 and more than 145 mmol/L, respectively. We assessed the influence on day 28 mortality of dysnatremia correction by day 3 and of the dysnatremia correction rate. Of 7,067 included patients, 1,830 (25.9%) had hyponatremia and 634 (9.0%) had hypernatremia at ICU admission (day 1). By day 3, hyponatremia had been corrected in 1,019 (1,019/1,830; 55.7%) and hypernatremia in 393 (393/634; 62.0%) patients. After adjustment for confounders, persistent hyponatremia or hypernatremia on day 3 was independently associated with higher day 28 mortality (odds ratio [OR], 1.31; 95% confidence interval [95% CI], 1.06 – 1.61; and OR, 1.86; 95% CI, 1.37 – 2.54; respectively). Hyponatremia corrected by day 3, hypernatremia corrected by day 3, and ICU-acquired hyponatremia were not associated with day 28 mortality. Median correction rate from days 1 to 3 was 2.58 mmol/L per day (interquartile range, 0.67 – 4.55). Higher natremia correction rate was associated with lower crude and adjusted day 28 mortality rates (OR per mmol/L per day, 0.97; 95% CI, 0.94 – 1.00; P = 0.04; and OR per mmol/L per day, 0.93; 95% CI, 0.90 – 0.97; P = 0.0003, respectively). Our results indicate that dysnatremia correction is independently associated with survival, with the effect being greater with faster correction rates of up to 12 mmol/L per day.

Urgent face-to-face tracheal re-intubation using Video-Airtraq™ in ICU patients placed in the sitting position

Dear Editor, Use of the video-assisted Airtraq laryngoscope (VAL: Vygon, Ecouen, France) allows fast and easy face-toface (ftf) orotracheal intubation in simulated difficult airway management conditions with the manikin placed in the sitting position facing the operator [1]. After clinical evaluation in operating room conditions, we propose the use of ftf-VAL reintubation (reI) in intensive care unit (ICU) patients placed in the sitting position, whose conventional tracheal intubation had been previously either difficult, as defined by an intubation difficulty score (IDS) of [5 [2], or impossible with the Macintosh laryngoscope (ML). We standardized the monitoring, pharmacological preparation, preoxygenation, rapid sequence anesthesia induction, and tracheal intubation techniques. Table 1 summarizes the details of initial difficult airway management and those of ftf-VAL-reI in the ICU. The airways of the 6 ICU patients placed in the sitting position were rapidly, easily, and safely secured using ftf-VAL-reI. This observation is spectacular in ICU patients because these patients are exposed to major complications [3]. Recommendations are now validated to secure tracheal intubation in the ICU [4]. Very recently De Jong et al. [5] showed that the use of videolaryngoscope (VL) enhanced the safety of tracheal intubation in the ICU. Our observations suggest that these technical advances could also favor the emergence of safer strategies of airway management such as ftf-VAL-reI. Our observation is certainly linked to the skill of the ICU physicians (instructors in our difficult airway management laboratory), but such performance mainly results from both the advantages of VL over ML and from the position of the patient. Firstly, ML is equipped with a blade of non-anatomical shape. It requires the operator to be placed behind the patient and requires skill with both hands. In contrast, VAL has an anatomical shape of reduced thickness (\20 mm), and the distal optical system allows one to view the glottis with minor mechanical constraint imposed on the anatomy. Tracheal intubation with the Airtraq laryngoscope relies upon single-hand dexterity to position the device in the pharynx; the other hand pushes the tracheal tube straight forward, guided by the channel of the device, into the trachea. Because of the video-assistance the Airtraq laryngoscope can now be inserted in any relative operator–patient position, and tracheal intubation skill only requires basic training. Secondly, the upright sitting position of the patient further simplifies the tracheal intubation maneuver with VAL. Indeed, rather than fighting against gravity, as with ML, the

Aspergillus mediastinitis after cardiac surgery

BACKGROUND Mediastinitis is a serious complication after cardiac surgery. While bacteria are the more common pathogens, fungal infections are rare. In particular, several cases of postoperative Aspergillus mediastinitis have been reported, the majority of which had an extremely poor outcome. METHODS A case of mediastinitis in a 42-year-old patient due to Aspergillus fumigatus after cardiac surgery is described. Two main risk factors were found: cardiogenic shock requiring veno-arterial extracorporeal life support and failure of primary closure of the sternum. A full recovery was attained after surgical drainage and antifungal therapy with liposomal amphotericin B, followed by a combination of voriconazole and caspofungin. The patient was followed for 18 months without relapse. RESULTS This is an extremely rare case of postoperative Aspergillus mediastinitis exhibiting a favourable outcome. Based on a systematic review of the literature, previous cases were examined with a focus on risk factors, antifungal therapies, and outcomes. CONCLUSION The clinical features of postoperative Aspergillus mediastinitis may be paucisymptomatic, emphasizing the need for a low index of suspicion in cases of culture-negative mediastinitis or in indolent wound infections. In addition to surgical debridement, the central component of antifungal therapy should include amphotericin B or voriconazole.

Acute Lower Limb Ischemia After Coronary Artery Bypass Grafting

THE INTERNAL MAMMARY ARTERY (IMA) is used as the conduit of choice in coronary artery bypass grafting (CABG) due to its superior long-term outcomes compared to venous grafts. The IMA collateralizes to the external iliac artery by anastomosis with the inferior epigastric artery. In patients with chronic aortoiliac occlusion, arterial perfusion of the lower limbs may be supplied mostly by this collateral pathway. In this case report, the authors describe the occurrence of acute bilateral lower limb ischemia following CABG using bilateral IMA grafts in a patient with severe aortoiliac occlusive disease.