Nicolas Pichon

Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to ventricular fibrillation.

IntroductionSince 2003, we have routinely used percutaneous coronary intervention (PCI) and mild therapeutic hypothermia (MTH) to treat patients < 80 years of age after out-of-hospital cardiac arrest (OHCA) related to ventricular fibrillation. The aim of our study was to evaluate the prognostic impact of routine PCI in association with MTH and the potential influence of age.MethodsWe studied 111 consecutive patients resuscitated successfully following OHCA related to shock-sensitive rhythm. They were divided into five groups according to age: < 45 years (n = 22, group 1), 45 to 54 years (n = 27, group 2), 55 to 64 years (n = 22, group 3), 65 to 74 years (n = 23, group 4) and ≥75 years (n = 17, group 5). Emergency coronary angiography was performed in hemodynamically stable patients < 80 years old, regardless of the electrocardiogram pattern. MTH was targeted to a core temperature of 32°C to 34°C for 24 hours.ResultsMost patients (73%) had coronary heart disease, although its incidence in group 1 was lower than in other groups (41% versus 81%; P = 0.01). In group 1, all patients but one underwent coronary angiography, and 33% of them underwent associated PCI. In group 5, only 53% of patients underwent a coronary angiography and 44% underwent PCI. Overall in-hospital survival was 54%, ranging between 52% and 64% in groups 1 to 4 and 24% in group 5. Time from collapse to return of spontaneous circulation was associated with mortality (odds ratio (OR) = 1.05 (25th to 75th percentile range, 1.03 to 1.08); P < 0.001), whereas PCI was associated with survival (OR = 0.30 (25th to 75th percentile range, 0.11 to 0.79); P = 0.01).ConclusionsWe suggest that routine coronary angiography with potentially associated PCI may favorably alter the prognosis of resuscitated patients with stable hemodynamics who are treated with MTH after OHCA related to ventricular fibrillation. Although age was not an independent cause of death, the clinical relevance of this therapeutic strategy remains to be determined in older people.

Endovascular versus External Targeted Temperature Management for Out-of-Hospital Cardiac Arrest Patients: A Randomized Controlled Study

Background— Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. Methods and Results— Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1–2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93–2.16; P=0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96–2.35; P=0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group (P<0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group (P=0.009). Conclusion— Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00392639.

Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients

IntroductionAssessment of cardiac function is key in the management of intensive care unit (ICU) patients and frequently relies on the use of standard transthoracic echocardiography (TTE). A commercially available new generation ultrasound system with two-dimensional imaging capability, which has roughly the size of a mobile phone, is adequately suited to extend the physical examination. The primary endpoint of this study was to evaluate the additional value of this new miniaturized device used as an ultrasonic stethoscope (US) for the determination of left ventricular (LV) systolic function, when compared to conventional clinical assessment by experienced intensivists. The secondary endpoint was to validate the US against TTE for the semi-quantitative assessment of left ventricular ejection fraction (LVEF) in ICU patients.MethodsIn this single-center prospective descriptive study, LVEF was independently assessed clinically by the attending physician and echocardiographically by two experienced intensivists trained in critical care echocardiography who used the US (size: 135 × 73 × 28 mm; weight: 390 g) and TTE. LVEF was visually estimated semi-quantitatively and classified in one of the following categories: increased (LVEF > 75%), normal (LVEF: 50 to 75%), moderately reduced (LVEF: 30 to 49%), or severely reduced (LVEF < 30%). Biplane LVEF measured using the Simpsons rule on TTE loops by an independent investigator was used as reference.ResultsA total of 94 consecutive patients were studied (age: 60 ± 17 years; simplified acute physiologic score 2: 41 ± 15), 63 being mechanically ventilated and 36 receiving vasopressors and/or inotropes. Diagnostic concordance between the clinically estimated LVEF and biplane LVEF was poor (Kappa: 0.33; 95% CI: 0.16 to 0.49) and only slightly improved by the knowledge of a previously determined LVEF value (Kappa: 0.44; 95% CI: 0.22 to 0.66). In contrast, the diagnostic agreement was good between visually assessed LVEF using the US and TTE (Kappa: 0.75; CI 95%: 0.63 to 0.87) and between LVEF assessed on-line and biplane LVEF, regardless of the system used (Kappa: 0.75; CI 95%: 0.64 to 0.87 and Kappa: 0.70; CI 95%: 0.59 to 0.82, respectively).ConclusionsIn ICU patients, the extension of physical examination using an US improves the ability of trained intensivists to determine LVEF at bedside. With trained operators, the semi-quantitative assessment of LVEF using the US is accurate when compared to standard TTE.

Albumin dialysis: a new therapeutic alternative for severe diltiazem intoxication.

In their recent experimental study, Sen et al. (1) showed that Molecular Adsorbents Recirculating System (MARS) could remove efficiently both albumin and protein-bound drugs from the plasma. The authors herein report the first case of successful blood detoxification using MARS therapy allowing full recovery in a patient presenting with a refractory shock secondary to acute diltiazem poisoning. A depressive 55-year-old woman was admitted to our intensive care unit in shock 4 h after the intentional ingestion of 28 tablets of 300 mg sustained-release diltiazem. Upon admission, a severe hypotension (45/24 mmHg) was associated with bradycardia (56 bpm) and oliguria. The patient underwent immediate gastric lavage and received activated charcoal (50 g). Electrocardiogram recorded a sinus bradycardia associated with first-degree atrioventricular block. Despite aggressive fluid resuscitation (7000 mL), repeated intravenous injection of calcium (10 g) and glucagon (9 mg), and vasopressive support, the marked hypotension became refractory to increasing doses of vasopressors (epinephrine and norepinephrine: 1.34 μg/Kg/min). Transesophageal echocardiography depicted a mild-to-moderate left ventricular systolic dysfunction and no finding consistent with cardiac preload dependence. Eight hours after the admission, biological abnormalities were an acute renal failure (creatinine: 164 μmol/L) and a metabolic acidosis (pH: 7.03; bicarbonates: 7 mmol/L; base excess: -22 mmol/L) associated with high circulating lactate level (20.1 mmol/L). Serum diltiazem concentration was 6421 nmol/L (therapeutic range: 170–480 nmol/L). Considering the deterioration of hemodynamics, despite aggressive resuscitation and the high proportion of circulating diltiazem (80% at therapeutic levels) bound to proteins (mainly albumin and alpha-1-acid glycoprotein) (2), blood detoxification based on albumin dialysis using MARS therapy was subsequently performed. Three hours after MARS therapy initiation, blood samples were withdrawn every 2 h for 24 h to measure serum diltiazem and desacetyldiltiazem concentrations using liquid chromatography-diode array detection. During the procedure, blood lactate level declined, doses of vasopressors were rapidly tapered and definitely discontinued 6 h after the albumin dialysis initiation (Fig. 1). The patient fully recovered, and was discharged on day 5 with a normal transthoracic echocardiogram. Severe calcium channel blocker overdose can result in marked and sustained hypotension (3). Although hemodynamic side-effects of calcium channel blockers are potentially reversible, the mortality of severe diltiazem overdose remains as high as 10% (3). As far as we know, no blood detoxification system has yet been shown to improve life-threatening circulatory failure secondary to severe overdose with calcium channel blockers (4). The MARS therapy is a new blood detoxification technique based on albumin dialysis, using a double-sided, albumin impregnated, hollow-fibre dialysis membrane as a molecular adsorbent in a closed-loop dialysis circuit (5). Toxins that are normally degraded in the liver and not cleared by conventional hemodialysis can be selectively removed from the circulation using this system. Our case report shows that extracorporeal albumin dialysis using MARS has the potential of efficiently removing protein-bound drugs from the circulation, thereby improving hemodynamic status. As such, this newly available system may be valuable in patients who sustain life-threatening hemodynamic compromise, despite symptomatic treatment in the setting of overdose from protein-binding drugs, that otherwise cannot be efficiently removed from the body.

Acute Toxic Herbal Intake in a Suicide Attempt and Fatal Refractory Ventricular Arrhythmia

This report involves a 54-year-old man who died following refractory ventricular fibrillation after ingestion of a plant in a suicide attempt. Repeated direct-current cardioversions were unsuccessful and no single anti-arrhythmic agent was effective for arrhythmia control. The routine blood toxicological screening was negative. Aconitine, the main toxin of Aconitum napellus was identified using a specific liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. The whole blood concentration (24 microg/l) was higher than those reported in other aconitine-related deaths. The patient had found information about the life-threatening nature of such a toxic herb intake on a free medical encyclopedia online.

Embolization of Rectal Arteries: An Alternative Treatment for Hemorrhagic Shock Induced by Traumatic Intrarectal Hemorrhage

Rectal injuries caused by foreign bodies or iatrogenic insertions may lead to severe complications whose therapeutic management remains controversial. At times, both the rapid identification and treatment of subsequent active rectal bleeding may be challenging, especially when endoscopy fails to locate and control the arterial hemorrhage. We present the first two successful cases of middle rectal artery embolization in patients presenting with sustained bleeding and hemorrhagic shock.

Potential side effect of propofol and sevoflurane for anesthesia of anti-NMDA-R encephalitis

BackgroundMany anesthetic drugs interact with the NMDA receptor and may therefore alter the clinical presentation of anti-NMDA-R encephalitis.Case presentationA 24-year-old woman was admitted to hospital for decreased consciousness and hyperthermia. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis, and elevated protein. Cultures were negative. Patient state worsened with agitation, facial dyskinesia, ocular deviation, and limb dystonia. Diagnosis of anti-NMDA-R encephalitis was evidenced by specific antibodies. High doses of methylprednisolone were administered. CT scan disclosed an ovarian teratoma and tumor resection was scheduled under anesthesia with propofol, sufentanil, atracurium and sevoflurane. Sedation after surgery was maintained with propofol. Rapidly after surgery, patient’s condition deteriorated with increase of dyskinesias, and two tonic-clonic generalized seizure events.ConclusionIn patients with anti-NMDA-R encephalitis, anesthesia using benzodiazepines, opiates and curares, which fail to interfere with the NMDA pathway, should be preferred.

Fatal thrombotic event after infusion of recombinant activated factor VII after cardiac surgery

Hemorrhagic shock is a major complication of cardiothoracic surgery that occurs when standard surgical and medical hemostatic procedures fail to stop hemorrhage. Recombinant activated factor VII (rFVIIa; NovoSeven, NovoNordisk, Denmark)is aprohemostatic agentincreasingly used as rescue therapy in cardiothoracic surgery, but its safety in this indication remains to be investigated. We report a fatal thrombotic event that occurred within 48 hours after the administration of rFVIIa for a refractory hemorrhagic shock after cardiothoracic surgery.

Fatal-stroke syndrome revealing fungal cerebral vasculitis due to Arthrographis kalrae in an immunocompetent patient.

ABSTRACT We report an uncommon clinical presentation of a unique case of fatal invasive fungal cerebral vasculitis due to Arthrographis kalrae in a nonimmunocompromised host. The identity of the fungus was determined by morphological characteristics and by analysis of internal transcribed spacer 1 sequences and was confirmed by postmortem examination of the brain tissues. Establishing rapidly the link between the clinical syndromes and the fungal infection of the central nervous system is essential to improve the outcome. As our case has shown, it is more challenging to make a diagnosis of fungal infection when there are no risk factors of immunodeficiency and when the clinical presentation seems uncommon.

Monitoring of metformin-induced lactic acidosis in a diabetic patient with acute kidney failure and effect of hemodialysis.

Metformin associated lactic acidosis (MALA) is a serious complication occurring especially in elderly patients given high doses of the drug. We report a non-fatal case of MALA with pronounced acidosis (pH 6.76, lactate 30.81 mmol/l) and high metformin concentrations (127 mg/l) in a patient who had developed acute renal failure after undergoing an operation. Multiple measurements of biological parameters and metformin blood concentrations showed the effectiveness of repeated hemodialysis sessions on metformin elimination. Cases previously reported with such a severe MALA were associated with a high mortality rate. We show that close monitoring in an intensive care unit together with prompt and repeated dialysis sessions can lead to a favorable outcome.