Jean-Damien Ricard

Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial.

Importance In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization. Objective To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. Design, Setting, and Participants Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up. Interventions Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia. Main Outcomes and Measures The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications. Results Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, −2.5% [95% CI, −11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%]; P = .37). Conclusions and Relevance Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels. Trial Registration clinicaltrials.gov Identifier: NCT02413723

A Randomized Trial of the Amikacin Fosfomycin Inhalation System for the Adjunctive Therapy of Gram-Negative Ventilator-Associated Pneumonia: IASIS Trial

BACKGROUND: Clinical failures in ventilator‐associated pneumonia (VAP) caused by gram‐negative bacteria are common and associated with substantial morbidity, mortality, and resource utilization. METHODS: We assessed the safety and efficacy of the amikacin fosfomycin inhalation system (AFIS) for the treatment of gram‐negative bacterial VAP in a randomized double‐blind, placebo‐controlled, parallel group, phase 2 study between May 2013 and March 2016. We compared standard of care in each arm plus 300 mg amikacin/120 mg fosfomycin or placebo (saline), delivered by aerosol twice daily for 10 days (or to extubation if < 10 days) via the investigational eFlow Inline System (PARI GmbH). The primary efficacy end point was change from baseline in the Clinical Pulmonary Infection Score (CPIS) during the randomized course of AFIS/placebo, using the subset of patients with microbiologically proven baseline infections with gram‐negative bacteria. RESULTS: There were 143 patients randomized: 71 to the AFIS group, and 72 to the placebo group. Comparison of CPIS change from baseline between treatment groups was not different (P = .70). The secondary hierarchical end point of no mortality and clinical cure at day 14 or earlier was also not significant (P = .68) nor was the hierarchical end point of no mortality and ventilator‐free days (P = .06). The number of deaths in the AFIS group was 17 (24%) and 12 (17%) in the placebo group (P = .32). The AFIS group had significantly fewer positive tracheal cultures on days 3 and 7 than placebo. CONCLUSIONS: In this trial of adjunctive aerosol therapy compared with standard of care IV antibiotics in patients with gram‐negative VAP, the AFIS was ineffective in improving clinical outcomes despite reducing bacterial burden. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01969799; URL: www.clinicaltrials.gov

Acute kidney injury in critical care: Experience of a conservative strategy

PURPOSE Renal replacement therapy (RRT) is a major supportive treatment of acute kidney injury (AKI) in intensive care unit (ICU), but the timing of its initiation remains open to debate. MATERIALS AND METHODS We retrospectively analyzed ICU patients who had AKI associated with at least one usual RRT criteria: serum creatinine concentration greater than 300 μmol/L, serum urea concentration greater than 25 mmol/L, serum potassium concentration greater than 6.5 mmol/L, severe metabolic acidosis (arterial blood pH<7.2), oliguria (urine output<135 mL/8 hours or <400 mL/24 hours), overload pulmonary edema. To estimate the risk of death associated with RRT adjusted for risk factors, we performed a marginal structural Cox model with inverse-probability-of-treatment-weighted estimator. RESULTS Among 4173 patients admitted to the ICU, 203 patients fulfilled potential RRT criteria. Ninety-one patients (44.8%) received RRT and 112 (55.2%) did not. Non-RRT and RRT patients differed in terms of severity of illness: Simplified Acute Physiology Score II (55±17 vs 60±19, respectively; P<.05) and Sequential Organ Failure Assessment score (8 [5-10] vs 9 [7-11], respectively; P=.01). Crude analysis indicated a lower ICU mortality for non-RRT compared with RRT patients (18% vs 45%; P<.001). In the marginal structural Cox model, RRT was associated with increased mortality (P<.01). CONCLUSION A conservative approach of AKI was not associated with increased mortality.

Risks of nonsteroidal antiinflammatory drugs in undiagnosed intensive care unit pneumococcal pneumonia: younger and more severely affected patients.

PURPOSE The purpose of this study is to investigate whether exposure to nonsteroidal antiinflammatory drugs (NSAIDs) at the early stage of severe pneumococcal community-acquired pneumonia (CAP) requiring intensive care unit (ICU) admission may affect its presentation and outcome. MATERIAL AND METHODS Medical records of ICU adult patients (12-year period) with a pneumococcal CAP diagnosis were retrospectively analyzed according to previous NSAID exposure. RESULTS One hundred six confirmed pneumococcal CAP were identified, 20 received NSAIDs within 4 (2-6) days before admission. Nonsteroidal antiinflammatory drug-exposed patients were younger (43.3 vs 62.2 years; P < .0001), had less frequently at least one chronic comorbid condition (40% vs 75%; P = .003), had more often complicated pleural effusions (20% vs 2.3%; P = .01), and more frequent pleuropulmonary complications (odds ratio: 5.75 [1.97-16.76]). Nonsteroidal antiinflammatory drug patients required more often noninvasive ventilatory support (25% vs 4.6%; P = .003). Intensive care unit length of stay and mortality were similar. CONCLUSIONS We report as severe pneumococcal pneumonia in young and healthy patients exposed to NSAIDs as in older, more comorbid, and nonexposed ones. Nonsteroidal antiinflammatory drug use may mask initial symptoms and delay antimicrobial therapy, thus predisposing to worse outcomes.

Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index

PURPOSE The purpose of the study is to describe early predictors and to develop a prediction tool that accurately identifies the need for mechanical ventilation (MV) in pneumonia patients with hypoxemic acute respiratory failure (ARF) treated with high-flow nasal cannula (HFNC). MATERIALS AND METHODS This is a 4-year prospective observational 2-center cohort study including patients with severe pneumonia treated with HFNC. High-flow nasal cannula failure was defined as need for MV. ROX index was defined as the ratio of pulse oximetry/fraction of inspired oxygen to respiratory rate. RESULTS One hundred fifty-seven patients were included, of whom 44 (28.0%) eventually required MV (HFNC failure). After 12 hours of HFNC treatment, the ROX index demonstrated the best prediction accuracy (area under the receiver operating characteristic curve 0.74 [95% confidence interval, 0.64-0.84]; P<.002). The best cutoff point for the ROX index was estimated to be 4.88. In the Cox proportional hazards model, a ROX index greater than or equal to 4.88 measured after 12 hours of HFNC was significantly associated with a lower risk for MV (hazard ratio, 0.273 [95% confidence interval, 0.121-0.618]; P=.002), even after adjusting for potential confounding. CONCLUSIONS In patients with ARF and pneumonia, the ROX index can identify patients at low risk for HFNC failure in whom therapy can be continued after 12 hours.

High-flow nasal oxygen for bronchoalveolar lavage in acute respiratory failure patients

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) holds significant risks of oxygenation deterioration [1]. Among various means to improve oxygenation during BAL, noninvasive positive pressure ventilation (NPPV) has received the greatest attention [2, 3]. However, NPPV is a time-consuming and very demanding technique. High-flow nasal cannula oxygen therapy (HFNC) has emerged as a technique for noninvasive respiratory management of hypoxaemic patients [4]. In patients with acute respiratory failure (ARF), its beneficial effects have been shown in various populations [5], and its effectiveness and superiority over NPPV and conventional oxygenation recently demonstrated [6]. Its use has also been described during bronchoscopy in non-hypoxaemic [7] and in hypoxaemic patients in comparison with NPPV [8]. However, bronchoscopy was performed with an open mouth in both studies, which considerably reduces HFNC efficacy [9]. Thus, we aimed to determine HFNCs effectiveness during nasal bronchoscopy with BAL in patients with ARF along with BALs feasibility and yield. HFNC is an effective and safe method of oxygenation during nasal bronchoscopy with BAL in hypoxaemic ARF patients http://ow.ly/XAmtZ

Total liquid ventilation offers ultra-fast and whole-body cooling in large animals in physiological conditions and during cardiac arrest

INTRODUCTION Total liquid ventilation (TLV) can cool down the entire body within 10-15 min in small animals. Our goal was to determine whether it could also induce ultra-fast and whole-body cooling in large animals using a specifically dedicated liquid ventilator. Cooling efficiency was evaluated under physiological conditions (beating-heart) and during cardiac arrest with automated chest compressions (CC, intra-arrest). METHODS In a first set of experiments, beating-heart pigs were randomly submitted to conventional mechanical ventilation or hypothermic TLV with perfluoro-N-octane (between 15 and 32 °C). In a second set of experiments, pigs were submitted to ventricular fibrillation and CC. One group underwent continuous CC with asynchronous conventional ventilation (Control group). The other group was switched to TLV while pursuing CC for the investigation of cooling capacities and potential effects on cardiac massage efficiency. RESULTS Under physiological conditions, TLV significantly decreased the entire body temperatures below 34 °C within only 10 min. As examples, cooling rates averaged 0.54 and 0.94 °C/min in rectum and esophageous, respectively. During cardiac arrest, TLV did not alter CC efficiency and cooled the entire body below 34 °C within 20 min, the low-flow period slowing cooling during CC. CONCLUSION Using a specifically designed liquid ventilator, TLV induced a very rapid cooling of the entire body in large animals. This was confirmed in both physiological conditions and during cardiac arrest with CC. TLV could be relevant for ultra-rapid cooling independently of body weight.

Costs associated with implementation of a strict policy for controlling spread of highly resistant microorganisms in France

Objective To assess costs associated with implementation of a strict ‘search and isolate’ strategy for controlling highly drug-resistant organisms (HDRO). Design Review of data from 2-year prospective surveillance (01/2012 to 12/2013) of HDRO. Setting Three university hospitals located in northern Paris. Methods Episodes were defined as single cases or outbreaks of glycopeptide-resistant enterococci (GRE) or carbapenemase-producing Enterobacteriacae (CPE) colonisation. Costs were related to staff reinforcement, costs of screening cultures, contact precautions and interruption of new admissions. Univariate analysis, along with simple and multiple linear regression analyses, was conducted to determine variables associated with cost of HDRO management. Results Overall, 41 consecutive episodes were included, 28 single cases and 13 outbreaks. The cost (mean±SD) associated with management of a single case identified within and/or 48 h after admission was €4443±11 552 and €11 445±15 743, respectively (p<0.01). In an outbreak, the total cost varied from €14 864 ±17 734 for an episode with one secondary case (€7432±8867 per case) to €136 525 ±151 231 (€12 845±5129 per case) when more than one secondary case occurred. In episodes of single cases, contact precautions and microbiological analyses represented 51% and 30% of overall cost, respectively. In outbreaks, cost related to interruption of new admissions represented 77–94% of total costs, and had the greatest financial impact (R2=0.98, p<0.01). Conclusions In HDRO episodes occurring at three university hospitals, interruption of new admissions constituted the most costly measure in an outbreak situation.

Low-dose corticosteroids during severe community-acquired pneumonia: end of the story

Community-acquired pneumonia (CAP) remains a leading cause of death worldwide despite improvement in patient management. Early recognition of lung infection and prompt initiation of adequate antibiotherapy are crucial elements to ensuring favourable outcomes [1–3]. Nonetheless, in a number of cases, death occurs despite both these targets being met. In these patients, possible excessive inflammatory responses, as in sepsis and septic shock, are believed to contribute to unfavourable outcome. Animal models have elegantly shown that part of the inflammatory response, initially destined to combat the pathogens invading the lungs (such as neutrophil products) may induce tissue damage even in the absence of any bacterial challenge [4]. They have also provided evidence that inhibiting inflammatory signalling lessens lung injury in murine models of Escherichia coli [5, 6] or Pseudomonas aeruginosa [7] pneumonia. These results and many others have prompted clinicians to investigate the potential benefit of administering corticosteroids to counterbalance an intense inflammatory process in order to improve outcome. This search has been a long and winding road which many researchers have taken with varying success. In cases of community-acquired pneumonia, corticosteroids should only be given if septic shock is also present http://ow.ly/FUCHN

The Case | A crystal-clear diagnosis: acute kidney injury in a patient with suspected meningoencephalitis

A 66-year-old man with no remarkable past history was referred to our department for suspected meningoencephalitis. Upon admission, prominent clinical features consisted of fever 38.3 °C, coma, and rhombencephalitis; his other vital signs and the remainder of the clinical examination were unremarkable. The serum creatinine and urea nitrogen levels were normal.