Samuel Lehingue

Early Hepatic Dysfunction Is Associated with a Worse Outcome in Patients Presenting with Acute Respiratory Distress Syndrome: A Post-Hoc Analysis of the ACURASYS and PROSEVA Studies

Introduction Bilirubin is well-recognized marker of hepatic dysfunction in intensive care unit (ICU) patients. Multiple organ failure often complicates acute respiratory distress syndrome (ARDS) evolution and is associated with high mortality. The effect of early hepatic dysfunction on ARDS mortality has been poorly investigated. We evaluated the incidence and the prognostic significance of increased serum bilirubin levels in the initial phase of ARDS. Methods The data of 805 patients with ARDS were retrospectively analysed. This population was extracted from two recent multicenter, prospective and randomised trials. Patients presenting with ARDS with a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen < 150 mmHg measured with a PEEP ≥ 5 cm of water were included. The total serum bilirubin was measured at inclusion and at days 2, 4, 7 and 14. The primary objective was to analyse the bilirubin at inclusion according to the 90-day mortality rate. Results The 90-day mortality rate was 33.8% (n = 272). The non-survivors were older, had higher Sepsis-related Organ Failure Assessment (SOFA) score and were more likely to have a medical diagnosis on admission than the survivors. At inclusion, the SOFA score without the liver score (10.3±2.9 vs. 9.0±3.0, p<0.0001) and the serum bilirubin levels (36.1±57.0 vs. 20.5±31.5 μmol/L, p<0.0001) were significantly higher in the non-survivors than in the survivors. Age, the hepatic SOFA score, the coagulation SOFA score, the arterial pH level, and the plateau pressure were independently associated with 90-day mortality in patients with ARDS. Conclusion Bilirubin used as a surrogate marker of hepatic dysfunction and measured early in the course of ARDS was associated with the 90-day mortality rate.

Tracheostomy tube through a silicone Y-stent for mechanical ventilation after an extensive tracheal lesion

From the R eanimation des D etresses Respiratoires et Infections S ev eres, Thoracic Endoscopy Unit, Department of Thoracic Surgery, Diseases of the Esophagus and Lung Transplantation, North Hospital, Aix-Marseille Universit e, Marseille, France. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication April 7, 2018; revisions received Oct 4, 2018; accepted for publication Oct 5, 2018; available ahead of print Nov 16, 2018. Address for reprints: Samuel Lehingue, MD, R eanimation des D etresses Respiratoires et Infections S ev eres, North Hospital, Aix-Marseille Universit e, 28 chemin du vallon de l’Oriol 13007 Marseille, France (E-mail: samlehingue@gmail.com). J Thorac Cardiovasc Surg 2019;157:e63-5 0022-5223/

Pharmacological Interventions: Neuromuscular Blocking Agents

36.00 Copyright 2018 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2018.10.034 A tracheostomy tube passing through the anterior wall of a Y-stent.

Cytomegalovirus reactivation in ICU patients.

Neuromuscular blocking agents (NMBAs) are extensively used in patients who present with acute respiratory distress syndrome (ARDS). The role of NMBAs has been extensively discussed in the past, primarily due to their potential adverse effects and the absence of clear evidence regarding their influence on prognosis. However, recent data have demonstrated that NMBAs are associated with a reduction in mortality in the most severe patients. Currently, the role of paralytics in the care of ARDS patients is proven. The positive effects of paralytics are probably due to the facilitation of protective ventilation, the prevention of ventilator-induced lung injury and the limitation of derecruitment. However, the role of NMBAs should be limited to severe and most hypoxaemic forms of moderate ARDS. NMBAs probably have a crucial role to play in the acute phase of ARDS, i.e. during the climax of lung injury, especially in association with other therapies, such as prone positioning. The use of NMBAs should always be integrated into the overall management strategy for the mechanical ventilation of ARDS patients, and NMBAs should be discontinued as soon as the patient improves sufficiently to allow for partial spontaneous breathing.