Nicolas Allou

Anesthesia and Perioperative Management of Patients Who Undergo Transfemoral Transcatheter Aortic Valve Implantation: An Observational Study of General Versus Local/Regional Anesthesia in 125 Consecutive Patients

OBJECTIVE To describe differences in intra- and postoperative care between general (GA) and local/regional anesthesia (LRA) in consecutive high-risk patients with aortic stenosis who underwent transfemoral transcatheter aortic valve implantation (TAVI). DESIGN A retrospective review of data collected in an institutional registry. SETTING An academic hospital. PARTICIPANTS One hundred twenty-five consecutive patients with severe aortic stenosis who underwent transfemoral TAVI. INTERVENTIONS GA versus LRA followed by postoperative care. Complications were defined by pre-established criteria. MATERIAL AND METHODS Consecutive patients referred for transfemoral TAVI between October 2006 and October 2010 initially underwent GA (n = 91) followed by LRA after March 2010 (n= 34). Results are presented as mean ± standard deviation or median (25-75 percentiles) as appropriate. GA and LRA TAVI patients had similar preoperative characteristics. LRA was associated with a significantly shorter procedure duration (LRA: 80 [67-102]; GA: 120 [90-140 minutes]; p < 0.001), hospital stay (LRA: 8.5 [7-14.5]; GA: 15.5 [10-24] days; p < 0.001), intraoperative requirements of catecholamines (LRA 23%; GA: 90% of patients; p < 0.001), and volume expansion (LRA: 11 [8-16]; GA: 22 [15-36] mL/kg; p < 0.001). There were significant differences in delta creatinine (day 1, preoperative creatinine values; LRA: 0 [-12 to 9]; GA: -15 (-25 to 2.9) μmol, p < 0.004). The frequency of any postoperative complications was 38% (LRA) and 77% (GA) (p = 0.11). Thirty-day mortality was 7% (GA) and 9% (LRA) (p = 0.9). CONCLUSIONS This observational study suggests that LRA was associated with less intraoperative hemodynamic instability and significant shortening of the procedure and hospital stay. Changes in the anesthetic technique adapted to changes in TAVI interventional techniques and did not increase the rate of postoperative complications.

Skin antisepsis with chlorhexidine–alcohol versus povidone iodine–alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial

BACKGROUND Intravascular-catheter-related infections are frequent life-threatening events in health care, but incidence can be decreased by improvements in the quality of care. Optimisation of skin antisepsis is essential to prevent short-term catheter-related infections. We hypothesised that chlorhexidine-alcohol would be more effective than povidone iodine-alcohol as a skin antiseptic to prevent intravascular-catheter-related infections. METHODS In this open-label, randomised controlled trial with a two-by-two factorial design, we enrolled consecutive adults (age ≥18 years) admitted to one of 11 French intensive-care units and requiring at least one of central-venous, haemodialysis, or arterial catheters. Before catheter insertion, we randomly assigned (1:1:1:1) patients via a secure web-based random-number generator (permuted blocks of eight, stratified by centre) to have all intravascular catheters prepared with 2% chlorhexidine-70% isopropyl alcohol (chlorhexidine-alcohol) or 5% povidone iodine-69% ethanol (povidone iodine-alcohol), with or without scrubbing of the skin with detergent before antiseptic application. Physicians and nurses were not masked to group assignment but microbiologists and outcome assessors were. The primary outcome was the incidence of catheter-related infections with chlorhexidine-alcohol versus povidone iodine-alcohol in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT01629550 and is closed to new participants. FINDINGS Between Oct 26, 2012, and Feb 12, 2014, 2546 patients were eligible to participate in the study. We randomly assigned 1181 patients (2547 catheters) to chlorhexidine-alcohol (594 patients with scrubbing, 587 without) and 1168 (2612 catheters) to povidone iodine-alcohol (580 patients with scrubbing, 588 without). Chlorhexidine-alcohol was associated with lower incidence of catheter-related infections (0·28 vs 1·77 per 1000 catheter-days with povidone iodine-alcohol; hazard ratio 0·15, 95% CI 0·05-0·41; p=0·0002). Scrubbing was not associated with a significant difference in catheter colonisation (p=0·3877). No systemic adverse events were reported, but severe skin reactions occurred more frequently in those assigned to chlorhexidine-alcohol (27 [3%] patients vs seven [1%] with povidone iodine-alcohol; p=0·0017) and led to chlorhexidine discontinuation in two patients. INTERPRETATION For skin antisepsis, chlorhexidine-alcohol provides greater protection against short-term catheter-related infections than does povidone iodine-alcohol and should be included in all bundles for prevention of intravascular catheter-related infections. FUNDING University Hospital of Poitiers, CareFusion.

Risk factors for postoperative pneumonia after cardiac surgery and development of a preoperative risk score

Objectives:The aims of this study were, first, to identify risk factors for microbiology-proven postoperative pneumonia after cardiac surgery and, second, to develop and validate a preoperative scoring system for the risk of postoperative pneumonia. Design and Setting:A single-center cohort study. Patients:All consecutive patients undergoing cardiac surgery between January 2006 and July 2011. Interventions:None. Measurements and Main Results:Multivariate analysis of risk factors for postoperative pneumonia was performed on data from patients operated between January 2006 and December 2008 (training set). External temporal validation was performed on data from patients operated between January 2009 and July 2011 (validation set). Preoperative variables identified in multivariate analysis of the training set were then used to develop a preoperative scoring system that was validated on the validation set. Postoperative pneumonia occurred in 174 of the 5,582 patients (3.1%; 95% CI, 2.7–3.6). Multivariate analysis identified four risk factors for postoperative pneumonia: age (odds ratio, 1.02; 95% CI, 1.01–1.03), chronic obstructive pulmonary disease (odds ratio, 2.97; 95% CI, 1.8–4.71), preoperative left ventricular ejection fraction (odds ratio, 0.98; 95% CI, 0.96–0.99), and the interaction between RBC transfusion during surgery and duration of cardiopulmonary bypass (odds ratio, 2.98; 95% CI, 1.96–4.54). A 6-point score including the three preoperative variables then defined two risk groups corresponding to postoperative pneumonia rates of 1.8% (score < 3) and 6.5% (score ≥ 3). Conclusion:Assessing preoperative risk factors for postoperative pneumonia with the proposed scoring system could help to implement a preventive policy in high-risk patients with a risk of postoperative pneumonia greater than 4% (i.e., patients with a score ≥3).

Preoperative iron deficiency increases transfusion requirements and fatigue in cardiac surgery patients: a prospective observational study.

Background Iron deficiency is the commonest cause of anaemia. It is apparent preoperatively in cardiac surgery patients and may influence transfusion requirements. In addition, iron deficiency per se is associated with fatigue. Objective To determine the prevalence of preoperative iron deficiency and its association with perioperative anaemia, blood transfusions and fatigue in cardiac surgery patients. Setting Academic hospital in Paris, France. Patients One hundred consecutive patients without known iron disorder and scheduled for cardiac surgery were prospectively included in this observational study. Intervention No intervention was performed. Measurements A biological iron profile (transferrin saturation, ferritin, soluble transferrin receptor and C-reactive protein) was assessed on the day of surgery. Diagnosis of iron deficiency was defined using a previously published algorithm. Patient fatigue was assessed before surgery and 1 week afterwards (day 7) using the Multidimensional Fatigue Inventory (MFI-20) score that quotes five distinctive dimensions of fatigue. Results Thirty-seven out of 100 patients were diagnosed with iron deficiency. These patients were younger [median (first-third quartile) 63 (43–70) vs. 70 (59–77) years (P = 0.004)], and more often female (51 vs. 21%, P = 0.003), than no iron deficiency patients. Preoperative iron deficiency was associated with lower preoperative haemoglobin levels (P = 0.006) and higher perioperative transfusion rates during the first week (62 vs. 35%, P = 0.019). Patients with iron deficiency but without anaemia (n = 25) received more packed red blood cells units than those without iron deficiency or anaemia (n = 50) [2 (0–2) vs. 0 (0–0) units, P < 0.05). Preoperative iron deficiency was associated with higher score of physical fatigue on day 7 (P = 0.01). Conclusion Preoperative iron deficiency is frequent among cardiac surgery patients and is associated with anaemia, higher transfusion requirements and postoperative fatigue.

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.

Incidence and risk factors of early thromboembolic events after mechanical heart valve replacement in patients treated with intravenous unfractionated heparin

Objective: To evaluate the incidence and risk factors, including timing and intensity of anticoagulation, of early thromboembolic events (TE) after mechanical heart valve replacement (MHVR) in patients treated by intravenous unfractionated heparin (IVUH). Design: Prospective observational study, conducted between December 2005 and May 2007. Setting: Haemostasis laboratory, surgical intensive care unit and ward in a university hospital. Patients: Three hundred consecutive patients undergoing MHVR. Mitral or double MHVR was performed in 149 patients, and aortic MHVR in 151 patients. Postoperative anticoagulation was achieved with continuous IVUH according to a standardised protocol. The timing of efficient anticoagulation was recorded for each patient. Main outcome measures: The end point was the occurrence of any arterial TE from day 1 to day 30. Transoesophageal echocardiography was systematically performed after mitral MHVR. Results: Early TE occurred in 22 patients (14.8%; 95% CI 9% to 20%) after a mitral or double MHVR and in two patients (1.3%; 95% CI 0% to 3%) after an aortic MHVR (p = 0.005). After adjustment for diabetes mellitus (adjusted OR (aOR) = 3.3; 95% CI 1.0 to 10.9, p = 0.049), and for the presence of predisposing factors (heparin-induced thrombocytopenia or bradycardia requiring definitive pacemaker implantation) (aOR = 12.8; 95% CI 3.1 to 53.3, p<0.001), effective anticoagulation on day 3 was a protective factor (aOR = 0.28; 95% CI 0.1 to 0.8, p = 0.018) for early TE after mitral MHVR. Conclusions: Despite the use of IVUH, the rate of early TE after mitral MHVR remained elevated. These results suggest that early effective anticoagulation is required after mitral MHVR, since inappropriate anticoagulation on day 3 was significantly associated with early TE.

Heparin-Induced Thrombocytopenia After Cardiac Surgery: An Observational Study of 1,722 Patients

OBJECTIVES To assess the characteristics and prognosis of patients in whom heparin-induced thrombocytopenia (HIT) was confirmed (HIT+) among suspected HIT patients after having cardiac surgery and to assess the accuracy of two HIT scoring systems. DESIGN An observational prospective study. SETTING A cardiac surgery unit of a tertiary center from November 2005 to September 2007. PARTICIPANTS Of the 1,722 patients who underwent cardiac surgery, 63 were suspected of HIT based on a platelet count <100 × 10(9)/L, a decrease in platelet count of >30%, or the occurrence of a thrombotic event. INTERVENTION The HIT criteria were as follows: (1) the absence of another cause of thrombocytopenia, (2) positive antiplatelet factor 4 (PF4) antibodies (>0.5 optical density [OD]/mn) on enzyme-linked immunoabsorbent assay, and (3) recovery in platelet count after the discontinuation of heparin and substitution by danaparoid sodium. MEASUREMENTS AND MAIN RESULTS HIT was confirmed in 24 patients (1.4% [0.8%-1.9%]); 23 belonged to the 984 treated by intravenous unfractionated heparin (IVUH) (2.3% IQ [1.4%-3.3%]) and 1 to the 738 treated by low-molecularweight heparin (0.14% [0.13%-0.4%]) (OD = 17.6; 95% confidence interval, 2.4-131; p < 0.0001). In the HIT+ patients compared with the unconfirmed HIT patients, thrombocytopenia occurred 7 (range, 6-9) days after surgery versus 3 (range, 3-5) days (p < 0.0001), and kinetics of platelet count showed a biphasic pattern. Six HIT+ patients (25% [7.7-42.3]) presented with an arterial thromboembolic event. Diagnosis performances of HIT scoring systems were low. CONCLUSIONS Confirmed HIT occurred predominantly in patients treated with IVUH. The timing of thrombocytopenia and the variation pattern of the postoperative platelet count are key factors in diagnosing HIT. The overall incidence of intracardiac thrombotic events was noted to be high.

When and How to Cover for Fungal Infections in Patients with Severe Sepsis and Septic Shock

Candida species remain the most frequently isolated fungi in intensive care unit (ICU) patients with severe sepsis or septic shock. Delayed antifungal therapy in these patients is a recognized risk factor for mortality. However, the diagnosis of invasive candidiasis remains difficult and is frequently delayed. Clinical scores have been proposed to assess the risk of development of invasive candidiasis or candidemia. Laboratory tools for early diagnosis are disappointing or still under development. Triazoles, polyenes, and echinocandins are the key drugs used to treat invasive candidiasis in ICU patients with similar efficacy, but very variable tolerability. The increasing incidence of fluconazole-resistant and susceptible-dose dependent strains and the safety profile of antifungal agents must be taken into account when selecting empiric therapy, frequently leading to the initial use of echinocandins in ICU patients with severe sepsis or septic shock.

Risk factors and prognosis of post-operative pneumonia due to Pseudomonas aeruginosa following cardiac surgery

Sir, Several studies among patients undergoing cardiac surgery (CS) have reported post-operative pneumonia (POP) as the main infectious complication usually involving nosocomial microorganisms. Due to the therapeutic issues raised by Pseudomonas aeruginosa infections, the choice of appropriate initial empirical antibiotic therapy (EAT) is of major importance, but has been minimally addressed in CS patients. We compared the incidence, risk factors, microbiological features, therapeutic management and outcome of POP due to P. aeruginosa with POP due to other organisms in this setting. This single-centre study performed in a tertiary care hospital from January 2005 to October 2007 prospectively evaluated 2540 patients undergoing CS with cardiopulmonary bypass admitted to a post-operative 15 bed CS intensive care unit (ICU). Cefamandole was used for surgical antibiotic prophylaxis (allergic patients received vancomycinþgentamicin). Diagnosis of POP was based on usual clinical and microbiological criteria, with bronchoalveolar lavage yielding bacteria at a concentration of .10 cfu/mL or protected distal bronchial specimen samples yielding .10 cfu/mL. Susceptibility testing was performed using the disc diffusion method. Eighty-two (3.2%) patients were diagnosed as having POP a median (interquartile range) of 4 (2) days after surgery, including 47 cases of ventilator-associated pneumonia (VAP) (57%) and 26 cases of POP due to P. aeruginosa (32%). A total of 122 microorganisms were cultured. POP due to P. aeruginosa was more frequently observed as a monomicrobial infection (65% versus 37% in other cases of POP, P1⁄40.02). In POP due to P. aeruginosa, most isolates were susceptible to the antibiotic agents, except for one P. aeruginosa strain resistant to piperacillin, three P. aeruginosa strains (12%) resistant to imipenem and three Enterobacteriaceae strains (50%) resistant to amoxicillin/ clavulanate. In the other group, 44% (n1⁄416) of Enterobacteriaceae were susceptible to amoxicillin/clavulanate and 100% were susceptible to broad-spectrum b-lactams and fluoroquinolones. One Acinetobacter strain was resistant to piperacillin/ tazobactam. POP due to P. aeruginosa was evenly distributed over the study period, with no evidence of clustering. Surveillance isolates from the environment showed that all isolates were different. EAT was more frequently inappropriate in the group with POP due to P. aeruginosa than in the other cases of POP (38% versus 7%, P,0.001) (Table 1). In multivariate analysis, POP due to P. aeruginosa was independently associated with previous antibiotic exposure in the 3 months before surgery [odds ratio (OR) 6.6; 95% confidence interval (CI) 1.8–25.2; P1⁄40.005], presence of a nasogastric tube (OR 6.8; 95% CI 1.5–31.8; P1⁄40.02), Simplified Acute Physiologic Score (SAPS II) per one point increase (OR 1.1; 95% CI 1.0–1.2; P1⁄40.003) and chronic obstructive pulmonary disease (COPD) (OR 6.0; 95% CI 1.5–23.0; P1⁄40.01). The model showed good calibration (Hosmer–Lemeshow goodness of fit test: P1⁄40.61) and discrimination [area under the receiver operating characteristic (ROC) curve: 0.83 (95% CI 0.75–0.93)]. Twenty-nine patients (35%) died after an interval of 15 (19) days following surgery; 15 (58%) of the 26 cases of POP due to P. aeruginosa versus 14 (25%) deaths among the other 56 patients (P1⁄40.004). Death was reported in 8 (57%) of the 14 patients who received inadequate EAT compared with 21 (31%) deaths among the 68 patients with adequate EAT (P1⁄40.07). Publications of POP following CS have usually confined their analysis to patients with VAP. We consider that extending the study population to non-VAP patients provides an interesting perspective, as VAP is not the only clinical presentation of POP, as illustrated by a study in which VAP represented only 36% of all cases of POP. Local guidelines are not used frequently in CS patients. Our local guidelines for EAT of nosocomial pneumonia take into account previous antibiotic therapy and duration of ICU stay, in line with the American Thoracic Surgery (ATS) guidelines. The attending physician should consider patients with POP as potentially harbouring multidrug-resistant (MDR) pathogens, while a low risk of multidrug resistance is only observed in early-onset nosocomial pneumonia ( 4 days). In all instances, a selection between limited-spectrum antibiotic therapy and broadspectrum treatment targeting MDR strains is based on this early/late onset segmentation. In light of our results, the risk of MDR pathogens in CS patients seems low, but the risk of POP due to P. aeruginosa justifies the use of broad-spectrum agents. The guidelines for initial EAT for CS patients with suspected POP have been modified in our institution. A stratification based on underlying diseases (presence of COPD), previous antibiotic therapy and severity of infection more accurately identifies patients suspected of harbouring P. aeruginosa strains. In these high-risk patients, broad-spectrum antibiotic agents targeting non-fermenting Gram-negative bacilli (piperacillin/tazobactam or imipenem alone or combined with aminoglycosides or ciprofloxacin) are used as EAT. Limited-spectrum antibiotic therapy (amoxicillin/ clavulanic acid or cefotaxime alone or combined with aminoglycosides or ciprofloxacin) is used in the remaining patients. This Research letters

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 8 days 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.