Philippe Gaudard

Active Bleeding after Cardiac Surgery: A Prospective Observational Multicenter Study

Main Objectives To estimate the incidence of active bleeding after cardiac surgery (AB) based on a definition directly related on blood flow from chest drainage; to describe the AB characteristics and its management; to identify factors of postoperative complications. Methods AB was defined as a blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or in case of reoperation for hemostasis during the first 12 postoperative hours. The definition was applied in a prospective longitudinal observational study involving 29 French centers; all adult patients undergoing cardiac surgery with cardiopulmonary bypass were included over a 3-month period. Perioperative data (including blood product administration) were collected. To study possible variation in clinical practice among centers, patients were classified into two groups according to the AB incidence of the center compared to the overall incidence: “Low incidence” if incidence is lower and “High incidence” if incidence is equal or greater than overall incidence. Logistic regression analysis was used to identify risk factors of postoperative complications. Results Among 4,904 patients, 129 experienced AB (2.6%), among them 52 reoperation. Postoperative bleeding loss was 1,000 [820;1,375] ml and 1,680 [1,280;2,300] ml at 6 and 24 hours respectively. Incidence of AB varied between centers (0 to 16%) but was independent of in-centre cardiac surgical experience. Comparisons between groups according to AB incidence showed differences in postoperative management. Body surface area, preoperative creatinine, emergency surgery, postoperative acidosis and red blood cell transfusion were risk factors of postoperative complication. Conclusions A blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or early reoperation for hemostasis seems a relevant definition of AB. This definition, independent of transfusion, adjusted to body weight, may assess real time bleeding occurring early after surgery.

Continuous venovenous renal replacement therapy in critically ill patients: A work load analysis

OBJECTIVES To evaluate the nursing workload related to two techniques of continuous renal replacement therapy. RESEARCH METHODOLOGY We analysed retrospectively the nursing work load caused directly by continuous renal replacement therapy in a cohort of patients admitted consecutively over 10 months. Two types of continuous renal replacement therapy have been compared: dialysis with regional citrate anticoagulation and haemodiafiltration with systemic heparin coagulation. SETTING Academic Hospital Intensive Care Unit. MAIN OUTCOME MEASURES The nursing workload was defined by the time spent in the management of continuous renal replacement therapy, including preparation of the circuit and related biological controls. RESULTS 60 patients underwent a total of 202 sessions of continuous renal replacement therapy. The nursing workload as expressed as % time of nursing care was similar (12.3 [9.4-18.8] vs 13.4 [11.7-17.0] %, for haemodiafiltration and dialysis respectively, P=0.06). However, the distribution of the nursing workload is different: the bigger proportion of care is circuit preparation in haemodiafiltration and biology control in dialysis. CONCLUSIONS Nursing time dedicated to continuous renal replacement therapy is similar whatever the renal replacement therapy technique. However, a longer duration of the filter and a better circuit predictability with dialysis and citrate anticoagulation are potential benefits for nursing workload.

Terlipressin, a vasoactive prodrug recommended in hepatorenal syndrome, is an agonist of human V1, V2 and V1B receptors: Implications for its safety profile.

Terlipressin is recommended as a gold standard to treat hepatorenal syndrome complicating liver cirrhosis. It is presented as a specific V1A receptor agonist, beyond its enzymatic conversion into lysine8-Vasopressin (LVP), able to counteract the splanchnic vasodilation. However, the complete pharmacological characterization of this drug with respect to the different vasopressin receptor subtypes is missing. We studied terlipressin intrinsic properties, focusing not only on V1A, but also on other vasopressin receptor subtypes. The experimental studies were conducted on rat and human cellular models. Binding experiments were performed on rat liver membranes and CHO cells transfected with the different human vasopressin receptor subtypes. Agonist status was assessed from inositol phosphate or cyclic AMP assays, and measurement of intracellular calcium variations, performed on cultured vascular smooth muscle cells from rat aorta and human uterine artery and CHO cells. Terlipressin binds to the rat and human V1A receptors with an affinity in the micromolar range, a value 120 fold lower than that of LVP. It induces a rapid and transient intracellular calcium increase, a robust stimulation of phospholipase C but with reduced maximal efficiencies as compared to LVP, indicating a partial V1A agonist property. In addition, terlipressin is also a full agonist of human V2 and V1B receptors, with also a micromomolar affinity. CONCLUSIONS Terlipressin is a non-selective vasopressin analogue, exhibiting intrinsic agonist properties. Its full V2 receptor agonism may result in renal effects potentially aggravating water retention and hyponatremia of cirrhosis.

Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients

AbstractObjectiveCatecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients. DesignWe performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality.Measurements and resultsFourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17–76%) and short-term mortality rate was 49% (21–69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8–3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4–6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0–6.0]).ConclusionsIn this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.

ScvO2 changes after red‐blood‐cell transfusion for anaemia in cardiothoracic and vascular ICU patients: an observational study

Haemoglobin threshold for transfusion has been significantly decreased, but haemoglobin plasma concentration may not be sufficient to assess the need of red‐blood‐cell (RBC) transfusion. Central venous oxygen saturation (ScvO2) is a clue of metabolic matching between O2 transport and consumption, which could help to assess when transfusion is appropriate once anaemia has been diagnosed in ICU patients.

Correction to: Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients

Because of a technical error, the code corresponding to the outcome for the Basir et al. cohort was mis-implemented in the original version of our article. Characteristics of the cohort are in fact the followings.

Management of advanced heart failure: a review

ABSTRACT Introduction: Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.

Disease-specific scoring or generic scoring in ICU?

Scoring systems are largely used in critically ill patients. Various scores have been developed over the last 30 years (1) to predict outcome at the early stage of ICU admission (within the first 24 hours), mainly in-hospital mortality but some are designed also to predict length of stay in ICU.

Influence of red blood cell transfusion on svco2 after cardiovascular surgery

The decision to transfuse is mainly taken according to hemoglobin level (Hb) (1,2) but venous oxygen saturation (SvO2) might be helpful to guide transfusion. We carried out a study to evaluate SvcO2 changes before and after blood transfusion after cardiovascular surgery. Methods. Patients admitted in ICU after cardiovascular surgery over 5 months (September 2014 to February 2015), who were transfused, have been included in the study. Patients with active bleeding, operated on emergency, or in critical condition were excluded. The decision to transfuse blood was made according to guidelines (1). Samples were collected through central venous catheter to measure respectively Hb and SvcO2 (co-oxymetry). Statistical analysis was performed with Mann-Whitney test. Data are expressed as median [25; 75%] and p o0.05 considered as statistically significant. Results. 100 consecutive patients have been included. Hb before transfusion was 7.3 g/dl [6.8; 7.8], SvcO2 66.9% [60; 73] without any correlation between both (Spearman r1⁄4 0.001; NS). SvcO2 was not significantly different between patients with Hb o 7 g/dL (n1⁄436) and patients with Hb Z 7g/dl (n1⁄464) (65.9% [59.3;77.7] vs. 67.7% [60.5;72.2] respectively; p1⁄40.92). SvcO2 after transfusion (RBC 2 [1;2]) increased significantly (71.9% [66.3;77.4]) as well as Hb (9.1 g/dL, [8.6;9.8]) (po0.001) but the observed change in Svc02 is related to patients with Svc02 o 65% before transfusion (po0.001), not when Svc02 Z 65%. Conclusions. According the study, 64% patients have high pretransfusion SvcO2 and experienced no SvcO2 improvement after transfusion, that questions its benefit. Whether a restrictive transfusion protocol guided by SvcO2 would be safe requires further studies.