Mélanie Adda

Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure

Objectives:The current trend to manage critically ill hematologic patients admitted with acute respiratory failure is to perform noninvasive ventilation to avoid endotracheal intubation. However, failure of noninvasive ventilation may lead to an increased mortality. Design:Retrospective study to determine the frequency of noninvasive ventilation failure and identify its determinants. Setting:Medical intensive care unit in a University hospital. Patients:All consecutive patients with hematologic malignancies admitted to the intensive care unit over a 10-yr period who received noninvasive ventilation. Results:A total of 99 patients were studied. Simplified Acute Physiology Score II at admission was 49 (median, interquartile range, 39–57). Fifty-three patients (54%) failed noninvasive ventilation and required endotracheal intubation. Their Pao2/Fio2 ratio was significantly lower (175 [101–236] vs. 248 [134–337]) and their respiratory rate under noninvasive ventilation was significantly higher (32 breaths/min [30–36] vs. 28 [27–30]). Forty-seven patients (89%) who failed noninvasive ventilation required vasopressors. Hospital mortality was 79% in those who failed noninvasive ventilation, and 41% in those who succeeded. Patients who failed noninvasive ventilation had a significantly longer intensive care unit stay (13 days [8–23] vs. 5 [2–8]) and a significantly higher rate of intensive care unit-acquired infections (32% compared with 7%). Factors independently associated with noninvasive ventilation failure by multivariate analysis were respiratory rate under noninvasive ventilation, longer delay between admission and noninvasive ventilation first use, need for vasopressors or renal replacement therapy, and acute respiratory distress syndrome. Conclusions:Failure of noninvasive ventilation occurs in half the critically ill hematologic patients and is associated with an increased mortality. Predictors of noninvasive ventilation failure might be used to guide decisions regarding intubation.

Right ventricular function during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.

Objective: To evaluate the effect of mean airway pressure under high-frequency oscillatory ventilation on right ventricular function. Design: Prospective randomized study. Setting: Intensive care unit of a tertiary care hospital. Patients: Sixteen consecutive patients within the first 48 hrs of mainly pulmonary acute respiratory distress syndrome. Interventions: After a 6-hr-period of protective conventional mechanical ventilation, patients were submitted to three 1-hr periods of high-frequency oscillatory ventilation (+ 5, + 10, + 15) in a randomized order, with a mean airway pressure level determined by adding 5, 10, or 15 cm H2O to the mean airway pressure recorded during conventional mechanical ventilation. Measurements and Main Results: Mean airway pressure was 18 ± 3 cm H2O during conventional mechanical ventilation and was increased until 33 ± 3 cm H2O at high-frequency oscillatory ventilation + 15. Right ventricular function was assessed using transesophageal echocardiography. During conventional mechanical ventilation, nine patients presented a right ventricular dysfunction (right ventricular end-diastolic area/left ventricular end-diastolic area ratio >0.6) of whom four patients had a right ventricular failure (right ventricular end-diastolic area/left ventricular end-diastolic area ratio >0.9). High-frequency oscillatory ventilation + 10 and + 15 further worsened right ventricular function, resulting in about a 40% increase in right ventricular end-diastolic area/left ventricular end-diastolic area ratio and a 30% increase in end-diastolic eccentricity index when compared with conventional mechanical ventilation or high-frequency oscillatory ventilation + 5 periods. At high-frequency oscillatory ventilation + 15, 15 patients had right ventricular dysfunction and nine had right ventricular failure. High-frequency oscillatory ventilation did not improve oxygenation whatever the mean airway pressure level. A significant redistribution of tidal variation to the posterior parts of the lung was observed on electrical impedance tomography measurements when increasing mean airway pressure. However, this redistribution was not observed in patients who presented a worsening of right ventricular function (right ventricular end-diastolic area/left ventricular end-diastolic area increase >40%) at high-frequency oscillatory ventilation + 15. Conclusions: In patients with mainly pulmonary acute respiratory distress syndrome, using high mean airway pressure under high-frequency oscillatory ventilation can worsen right ventricular function when compared with protective conventional mechanical ventilation, notably in patients in whom high-frequency oscillatory ventilation produced less alveolar recruitment of the posterior parts of the lungs. This study highlights the interest of monitoring right ventricular function during high-frequency oscillatory ventilation. (Crit Care Med 2012; 40:–6)

Complicated grief after death of a relative in the intensive care unit

An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score >25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives. Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements. End-of-life care and communication in the ICU are associated with the prevalence of complicated grief http://ow.ly/DCqjB

Comparison of femorofemoral and femorojugular configurations during venovenous extracorporeal membrane oxygenation for severe ARDS

Dear Editor, Schmidt et al. [1] recently demonstrated that an extracorporeal membrane oxygenation (ECMO) flow greater than 60 % of cardiac output was always associated with an SaO2 greater than 90 % during venovenous ECMO (vvECMO) for severe ARDS. We postulate that the configuration of the circuit may affect arterial oxygenation. We performed a retrospective comparative study of the medical charts of the patients according to ECMO configuration. During the oldest period, cannulation was performed with a femorofemoral (FF) configuration according to the experience of the ANZIC group [2], whereas during the latest period femorojugular (FJ) configuration was preferred. Details about the cannulas and the ECMO circuit’s components are available in previous publications [3, 4]. Nine patients with FF were compared with nine with FJ configuration (Table 1). In the case of the FF configuration, the drainage cannulation was inserted via the left femoral vein with the tip located at the junction between the iliac vein and the inferior vena cava, and the infusion cannula was inserted via the right femoral vein with the tip located at the junction between the right atrium and the inferior vena cava. In the case of the FJ configuration, the drainage cannula was inserted via the right femoral vein with the tip located at the junction

“It Was the Only Thing I Could Hold Onto, But…”: Receiving a Letter of Condolence After Loss of a Loved One in the ICU

Objectives: Family members of patients who die in the ICU often remain with unanswered questions and suffer from lack of closure. A letter of condolence may help bereaved relatives, but little is known about their experience of receiving such a letter. The objective of the study was to understand bereaved family members’ experience of receiving a letter of condolence. Design: Qualitative study using interviews with bereaved family members who received a letter of condolence and letters written by these family members to the ICU team. This study was designed to provide insight into the results of a larger randomized, controlled, multicenter study. Setting: Twenty-two ICUs in France. Subjects: Family members who lost a loved one in the ICU and who received a letter of condolence. Measurements and Main Results: Thematic analysis was used and was based on 52 interviews and 26 letters. Six themes emerged: 1) a feeling of support, 2) humanization of the medical system, 3) an opportunity for reflection, 4) an opportunity to describe their loved one, 5) continuity and closure, and 6) doubts and ambivalence. Possible difficulties emerged, notably the re-experience of the trauma, highlighting the absence of further support. Conclusions: This study describes the benefits of receiving a letter of condolence; mainly, it humanizes the medical institution (feeling of support, confirmation of the role played by the relative, supplemental information). However, this study also shows a common ambivalence about the letter of condolence’s benefit. Healthcare workers must strive to adapt bereavement follow-up to each individual situation.