Sigismond Lasocki

Extracorporeal life support for patients with acute respiratory distress syndrome: report of a Consensus Conference

The influenza H1N1 epidemics in 2009 led a substantial number of people to develop severe acute respiratory distress syndrome and refractory hypoxemia. In these patients, extracorporeal membrane oxygenation was used as rescue oxygenation therapy. Several randomized clinical trials and observational studies suggested that extracorporeal membrane oxygenation associated with protective mechanical ventilation could improve outcome, but its efficacy remains uncertain. Organized by the Société de Réanimation de Langue Française (SRLF) in conjunction with the Société Française d’Anesthésie et de Réanimation (SFAR), the Société de Pneumologie de Langue Française (SPLF), the Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP), the Société Française de Perfusion (SOFRAPERF), the Société Française de Chirurgie Thoracique et Cardiovasculaire (SFCTV) et the Sociedad Española de Medecina Intensiva Critica y Unidades Coronarias (SEMICYUC), a Consensus Conference was held in December 2013 and a jury of 13 members wrote 65 recommendations to answer the five following questions regarding the place of extracorporeal life support for patients with acute respiratory distress syndrome: 1) What are the available techniques?; 2) Which patients could benefit from extracorporeal life support?; 3) How to perform extracorporeal life support?; 4) How and when to stop extracorporeal life support?; 5) Which organization should be recommended? To write the recommendations, evidence-based medicine (GRADE method), expert panel opinions, and shared decisions taken by all the thirteen members of the jury of the Consensus Conference were taken into account.

Iron deficiency in critically ill patients: highlighting the role of hepcidin

Iron is a paradoxical element, essential for living organisms but also potentially toxic. Indeed, iron has the ability to readily accept and donate electrons, interconverting from soluble ferrous form (Fe2+) to the insoluble ferric form (Fe3+). This capacity allows iron to play a major role in oxygen transport (as the central part of hemoglobin) but also in electron transfer, nitrogen fixation or DNA synthesis, all essential reactions for living organisms. Indeed, iron deficiency is the main cause of anemia [1] as well as a cause of fatigue [2], [3] and decreased effort capacity [4], [5]. However, despite a high frequency of anemia among critically ill patients, with 60 to 66 % being anemic at intensive care unit (ICU) admission [6], [7], to date little is known about iron deficiency and iron metabolism in critically ill patients [8]. The interaction between inflammation and iron metabolism interferes with the usual iron metabolism variables and renders this metabolism difficult to investigate [9], [10].

Early lung ultrasonography predicts the occurrence of acute respiratory distress syndrome in blunt trauma patients.

PurposeExtent of lung contusion on initial computed tomography (CT) scan predicts the occurrence of acute respiratory distress syndrome (ARDS) in blunt chest trauma patients. We hypothesized that lung ultrasonography (LUS) on admission could also predict subsequent ARDS.MethodsForty-five blunt trauma patients were prospectively studied. Clinical examination, chest radiography, and LUS were performed on arrival at the emergency room. Lung contusion extent was quantified using a LUS score and compared to CT scan measurements. The ability of the LUS score to predict ARDS was tested using the area under the receiver operating characteristic curve (AUC-ROC). The diagnostic accuracy of LUS was compared to that of combined clinical examination and chest radiography for pneumothorax, lung contusion, and hemothorax, with thoracic CT scan as reference.ResultsLung contusion extent assessed by LUS on admission was predictive of the occurrence of ARDS within 72xa0h (AUC-ROCxa0=xa00.78 [95xa0% CI 0.64–0.92]). The extent of lung contusion on LUS correlated well with CT scan measurements (Spearman’s coefficientxa0=xa00.82). A LUS score of 6 out of 16 was the best threshold to predict ARDS, with a 58xa0% [95xa0% CI 36–77] sensitivity and a 96xa0% [95xa0% CI 76–100] specificity. The diagnostic accuracy of LUS was higher than that of combined clinical examination and chest radiography: (AUC-ROC) 0.81 [95xa0% CI 0.50–1.00] vs. 0.74 [0.48–1.00] (pxa0=xa00.24) for pneumothorax, 0.88 [0.76–1.00] vs. 0.69 [0.47–0.92] (pxa0<xa00.05) for lung contusion, and 0.84 [0.59–1.00] vs. 0.73 [0.51–0.94] (pxa0<xa00.05) for hemothorax.ConclusionsLUS on admission identifies patients at risk of developing ARDS after blunt trauma. In addition, LUS allows rapid and accurate diagnosis of common traumatic thoracic injuries.

Ferric carboxymaltose increases epoetin-α response and prevents iron deficiency before elective orthopaedic surgery

Mots-clés Aged [6], Drug Synergism [7], Erythropoietin/therapeutic use [8], Female [9], Ferric Compounds/therapeutic use [10], Hematinics/therapeutic use [11], Hemoglobins/metabolism [12], Humans [13], Iron/blood/deficiency [14], Male [15], Maltose/analogs & derivatives/therapeutic use [16], Middle Aged [17], Orthopedic Procedures/methods [18], Preoperative Care [19], Recombinant Proteins/therapeutic use [20], Surgical Procedures, Elective [21] URL de la notice http://okina.univ-angers.fr/publications/ua8251 [22] DOI 10.1093/bja/aeu245 [23] Lien vers le document http://dx.doi.org/10.1093/bja/aeu245 [23] Titre abrégé Br J Anaesth

Prevalence of iron deficiency on ICU discharge and its relation with fatigue: a multicenter prospective study

IntroductionPrevalence of iron deficiency (ID) at intensive care (ICU) admission is around 25 to 40%. Blood losses are important during ICU stay, leading to iron losses, but prevalence of ID at ICU discharge is unknown. ID has been associated with fatigue and muscular weakness, and may thus impair post-ICU rehabilitation. This study assessed ID prevalence at ICU discharge, day 28 (D28) and six months (M6) after and its relation with fatigue.MethodsWe conducted this prospective, multicenter observational study at four University hospitals ICUs. Anemic (hemoglobin (Hb) less than 13 g/dL in male and less than 12 g/dL in female) critically ill adult patients hospitalized for at least five days had an iron profile taken at discharge, D28 and M6. ID was defined as ferritin less than 100 ng/L or less than 300 ng/L together with a transferrin saturation less than 20%. Fatigue was assessed by numerical scale and the Multidimensional Fatigue Inventory-20 questionnaire at D28 and M6 and muscular weakness by a hand grip test at ICU discharge.ResultsAmong 107 patients (men 77%, median (IQR) age 63 (48 to 73) years) who had a complete iron profile at ICU discharge, 9 (8.4%) had ID. At ICU discharge, their hemoglobin concentration (9.5 (87.7 to 10.3) versus 10.2 (92.2 to 11.7) g/dL, P =0.09), hand grip strength (52.5 (30 to 65) versus 49.5 (15.5 to 67.7)% of normal value, P =0.61) and visual analog scale fatigue scale (57 (40 to 80) versus 60 (47.5 to 80)/100, P =0.82) were not different from non-ID patients. At D28 (n =80 patients) and M6 (n =78 patients), ID prevalence increased (to 25 and 35% respectively) while anemia prevalence decreased (from 100% to 80 and 25% respectively, P <0.0001). ID was associated with increased fatigue at D28, after adjustment for main confounding factors, including anemia (regression coefficient (95%CI), 3.19 (0.74 to 5.64), P =0.012). At M6, this association disappeared.ConclusionsThe prevalence of ID increases from 8% at discharge to 35% six months after prolonged ICU stay (more than five days). ID was associated with increased fatigue, independently of anemia, at D28.

Impact of preoperative continuous femoral blockades on morphine consumption and morphine side effects in hip-fracture patients: A randomized, placebo-controlled study.

BACKGROUNDnUpon arrival at the emergency department, hip-fracture pain relief is usually carried out via systemic opioids. Continuous nerve blocks are efficient in the postoperative period, but have not been evaluated preoperatively. This study compared the reduction in morphine consumption and related side effects of a continuous femoral block with a single shot block in hip-fracture patients.nnnMETHODSnHip-fracture patients admitted to the emergency department received a femoral nerve catheter, with a single lidocaine injection. They were then randomized to ropivacaine (group R) or saline continuous infusion (placebo, group P) in a double-blind manner. Morphine consumption and side effects were prospectively collected until the 24th postoperative hour.nnnRESULTSnSixty patients were included and 55 analyzed. There were no significant differences between the 2 groups regarding fracture types, delay before surgery (median [Q1-Q3]: 21.3 [14.5-29.4] versus 20.8 [15.7-36.2] hours for groups R and P, respectively; P=0.87) and catheter duration (47.5 [39.8-52.4] versus 42.5 [32.1-50.5] hours, P=0.29). Total morphine consumption was not significantly decreased in group R (5 [0-14] versus 8 [4.5-11] mg, P=0.3) and pain scores were similar (mean±SD; VAS 29±15/100 versus 33±13, P=0.3). We observed a significant reduction in morphine adverse effects (31% versus 69% for groups R and P, respectively; P<0.01), mainly nausea (31% versus 59%, P=0.03). One morphine side effect could be avoided for every 5 patients treated.nnnCONCLUSIONnPreoperative continuous femoral blockades using ropivacaine reduce morphine side effects (mainly nausea) in hip-fracture patients without reducing morphine consumption.

The STOP-BANG questionnaire and the risk of perioperative respiratory complications in urgent surgery patients: A prospective, observational study

INTRODUCTIONnThe STOP-BANG (SB) questionnaire, a tool originally proposed for identifying patients at risk of obstructive sleep apnoea, may also identify patients at increased risk of perioperative complications (when>3). Perioperative complications, including respiratory ones, are more frequent in emergency surgery. This study aimed at evaluating whether the SB is predictive of perioperative respiratory complications in urgent surgery.nnnMETHODSnConsecutive adult patients admitted for an urgent surgery under general anaesthesia were included. The STOP-BANG questionnaire was completed before anaesthesia. Perioperative respiratory complications were prospectively recorded during surgery and in the postoperative care unit (PACU).nnnRESULTSnOne hundred and eighty-nine patients were included (women 46%, median age 60 [43-78] years old) of which 104 (55%) were SB+. Diabetes mellitus and arrhythmia were more frequent in the SB+ patients than in SB-. The ASA class was higher in SB+ patients compared with SB-, but type and duration of surgery were statistically similar. The incidence of respiratory complications was higher in SB+ patients both during surgery (21% versus 6%, P<0.002) and in the PACU (57% versus 34%, P=0.0015). Furthermore, SB+ patients had a prolonged length of hospital stay (6 [3-12] versus 4 [2-7] days, P=0.0002). In a multivariate analysis, the STOP-BANG score was independently associated with respiratory complications (OR [CI 95%]=1.44 [1.03-2.03], P=0.03).nnnCONCLUSIONSnAn elevated STOP-BANG score (≥ 3) is associated with an increased risk of perioperative respiratory complications and with prolonged length of stay in urgent surgery patients.

Iron deficiency without anemia is responsible for decreased left ventricular function and reduced mitochondrial complex I activity in a mouse model

BACKGROUNDnIron deficiency (ID), with or without anemia, is frequent in heart failure patients, and iron supplementation improves patient condition. However, the link between ID (independently of anemia) and cardiac function is poorly understood, but could be explained by an impaired mitochondrial metabolism. Our aim was to explore this hypothesis in a mouse model.nnnMETHODS AND RESULTSnWe developed a mouse model of ID without anemia, using a blood withdrawal followed by 3-weeks low iron diet. ID was confirmed by low spleen, liver and heart iron contents and the repression of HAMP gene coding for hepcidin. ID was corrected by a single ferric carboxymaltose (FCM) injection (IDu202f+u202fFCM mice). Hemoglobin levels were similar in ID, IDu202f+u202fFCM and control mice. ID mice had impaired physical performances and left ventricular function (echocardiography). Mitochondrial complex I activity of cardiomyocytes was significantly decreased in ID mice, but not complexes II, III and IV activities. IDu202f+u202fFCM mice had improved physical performance, cardiac function and complex I activity compared to ID mice. Using BN-PAGE, we did not observe complex I disassembly, but a reduced quantity of the whole enzyme complex I in ID mice, that was restored in IDu202f+u202fFCM mice.nnnCONCLUSIONSnID, independently of anemia, is responsible for a decreased left ventricular function, through a reduction in mitochondrial complex I activity, probably secondary to a decrease in complex I quantity. These abnormalities are reversed after iron treatment, and may explain, at least in part, the benefit of iron supplementation in heart failure patients with ID.

Impact of combined antibiotic treatment on multidrug-resistant bacteria emergence after postoperative intra-abdominal infections

Initial correspondence from Drs. Simeone, Lagier and Mokart We would like to congratulate Montravers et al. [1], on their study, which challenged medical dogma and demonstrated that short-duration (8 days) antibiotic regimen in critically ill patients treated for postoperative intraabdominal infections appeared to be safe as compared to extended antibiotic regimen (15 days). One striking message of this study is that the emergence of multidrugresistant (MDR) bacteria is associated with extended antibiotic regimen. In the article [1], the authors provided additional data (Supplementary Table S4) showing rates of combined antibiotic therapy, defined as the use of three or more antibiotics in each group: 35 of 116 (30%) in the 15-day arm versus 54 of 120 (45%) in the 8-day arm. No statistical analysis of these data was provided. However, a Fisher exact test shows that the two groups were significantly different as p = 0.022 with an odds ratio of 0.52 (0.29–0.93). Thus, the two groups were significantly different regarding the use of combined antibiotics therapy. Although clinical evidence is limited, several in vitro studies have underlined the interest in using antibiotic combinations in order to avoid MDR bacteria emergence [2, 3]. Unbalanced use of combined antibiotic therapy seems significant enough to raise some concerns about the observed effect regarding the lower MDR bacteria emergence in the short-duration antibiotic regimen group.

Is very short-course antibiotic therapy possible in postoperative intra-abdominal infections? Discussion on “Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: the DURAPOP randomised clinical trial”

Dear Editor, We read with great interest the paper presenting the results of the DURAPOP randomized clinical trial comparing the efficacy and safety of 8 days versus 15 days antibiotic therapy in critically ill patients with postoperative intra-abdominal infections (PIAI). The authors concluded that an 8-day antibiotic regimen reduced antibiotic exposure in ICU patients with proven PIAI without affecting outcome [1]. As the authors assessed, data about the optimal duration of antibiotic therapy for complicated intra-abdominal infections in ICU patients are lacking. In less severe patients with mild-to-moderate intra-abdominal infections, an even shorter course of 4 days has been shown to be as effective as longer treatments [2]. Our team conducted a study to evaluate the efficacy of a procalcitonin (PCT)-guided antibiotic therapy in critically ill patients with secondary peritonitis, of whom approximately 40% had nosocomial peritonitis (mostly postoperative) [3]. Duration of treatment in the PCTguided group was significantly shorter than in the nonPCT-guided group (5.1 ± 2.1 vs 10.2 ± 3.7 days) without affecting outcome. The severity of our patients, with a mean SAPS II of 43.4 ± 15.8 was comparable to that one reported by Montravers et al. [1], with a median SAPS II of 45 [IQR 34–51.8]. Our study suggests that antibiotic therapy duration may be shorter than the 8 days antibiotic regimen proposed by Montravers et al. [1] after adequate source control surgery. Very short treatments, of 4–5 days, may be safe by using PCT guidance, even in critically ill patients with proven PIAI. Shortening the antibiotic duration might reduce the emergence of multidrug-resistant bacteria in antimicrobial stewardship programs.