Talna Kortchinsky

Extracorporeal life support in lung and heart-lung transplantation for pulmonary hypertension in adults.

After bilateral lung and heart–lung transplantation in adults with pulmonary hypertension, hemodynamic and oxygenation deficiencies are life‐threatening complications that are increasingly managed with extracorporeal life support (ECLS). The primary aim of this retrospective study was to assess 30‐day and 1‐year survival rates in patients managed with vs without post‐operative venoarterial ECLS in 2008–2013. The secondary endpoints were the occurrence rates of nosocomial infection, bleeding, and acute renal failure. Of the 93 patients with pulmonary hypertension who received heart‐lung (n=29) or bilateral lung (n=64) transplants, 28 (30%) required ECLS a median of 0 [0–6] hours after surgery completion and for a median of 3.0 [2.0–8.5] days. Compared to ECLS patients, controls had higher survival at 30 days (95.0% vs 78.5%; P=.02) and 1 year (83% vs 64%; P=.005), fewer nosocomial infections (48% vs 79%; P=.0006), and fewer bleeding events (17% vs 43%; P=.008). The need for renal replacement therapy was not different between groups (11% vs 17%; P=.54). Venoarterial ECLS is effective in treating pulmonary graft dysfunction with hemodynamic failure after heart‐lung or bilateral lung. However, ECLS use was associated with higher rates of infection and bleeding.

PF4-heparin antibodies during ECMO: incidence, course, and outcomes.

Unfractionated heparin is the first-line anticoagulant treatment during extracorporeal membrane oxygenation (ECMO). Heparin-induced thrombocytopenia (HIT) is a rare but severe complication [1] and is challenging to diagnose after cardiopulmonary bypass [2]. The first-line laboratory test for diagnosing HIT is detection of PF4heparin antibodies (PF4-H) [1]. This test is highly sensitive [1] but lacks specificity after cardiopulmonary bypass [3]. The incidence and course of PF4-H positivity during ECMO remain unknown. Here we reported the incidence of PF4-H positivity over time in patients under ECMO, the relationship with HIT, and the outcomes of patients. Our institutional review board approved the study. Consecutive patients managed with ECMO for at least 72 h were identified prospectively and underwent PF4-H assays (Electronic Supplement Fig. 1). Patients were divided according to PF4-H positivity. A diagnosis of HIT needs a positive functional assay [2]. The 73 studied patients had 320 PF4-H assays performed. Among them, 22 (30.1 %; 95 % CI, 20.2–42.1) had at least one positive PF4-H assay. Characteristics and outcomes of patients are summarized in Table 1. Mean time from ECMO initiation to PF4-H seroconversion was 5.1 ± 3.5 days (0.0–13.0 days). Optical densities of positive PF4-H assays varied significantly over time, peaking between days 4 and 6 (1.10 ± 0.83 units). HIT was diagnosed in 3 (4.1 %; 95 % CI, 1.4–11.4) patients. The frequency of thrombotic events increased with the PF4-H titer, from 7/52 (13.5 %) when optical densities were less than 0.5 to 2/9 (22.2 %) when optical densities were between 0.5 and 1.0, and 7/12 (58.3 %) when optical densities were greater than 1.0 (P = 0.003). Platelet counts varied significantly over time (P < 0.0001), with no difference between patients with and without positive PF4-H (Electronic Supplement Fig. 2). The incidence of PF4-H positivity during ECMO is similar to that observed several days after cardiopulmonary bypass where PF4-H positivity ranged between 26 and 51 % [2, 3]. Although nearly a third of our patients had PF4-H, only 4 % were diagnosed with HIT. This incidence of HIT is higher than previously reported in patients after cardiothoracic surgery [2] or during ECMO [4]. Our work emphasizes the challenges raised by diagnosing HIT in patients receiving ECMO. The time-course of the platelet count was not discriminant [2, 3] and the 4Ts score failed to discriminate patients with and without positive PF4-H. During ECMO, a positive PF4-H assay, even with high optical density values, is not sufficient to diagnose HIT. Therefore, the diagnosis of HIT should be confirmed by a functional assay to avoid overdiagnosis [1]. However, receiver operating characteristics of functional assays during ECMO are unknown. We agree that serotonin release assay should be used when the PF4-H and platelet aggregation test results are discordant [2]. Importantly, a negative PF4-H assay rules out HIT [1]. Association between PF4-H positivity and thrombotic events has been previously reported [5] as PF4 itself can be prothrombotic. Patients with positive PF4-H had a trend toward higher mortality as previously reported [4]. However, the clinical comorbidities associated with the risk of death should be also taken into account [2, 4].

Fiber optic bronchoscopy and remifentanil target-controlled infusion in critically ill patients with acute hypoxaemic respiratory failure: A descriptive study

INTRODUCTION Sedation optimizes patient comfort and ease of execution during fiber optic bronchoscopy (FOB). Our objective was to describe the safety and efficacy of remifentanil-TCI during FOB in non-intubated, hypoxaemic, thoracic surgery ICU patients. METHODS Consecutive spontaneously breathing adults requiring FOB after thoracic surgery were included if they had hypoxaemia (PaO2/FiO2<300mmHg or need for non-invasive ventilation [NIV]) and prior FOB failure under topical anaesthesia. The remifentanil initial target was chosen at 1ng/mL brain effect-site concentration (Cet), then titrated to 0.5ng/mL Cet increments according to patient comfort and coughing. Outcomes were patient-reported pain and discomfort (Visual Analogue Scale scores), ventilatory support intensification within 24hours after bronchoscopy, and ease of FOB execution. RESULTS Thirty-nine patients were included; all had a successful FOB. Their median PO2/FiO2 before starting FOB was 187±84mmHg and 24 patients received NIV. Median [interquartile range] pain scores were not different before and after FOB (1.0 [0.0-3.0] and 0.0 [0.0-2.0], respectively). Discomfort was reported as absent or minimal by 27 patients (69%; 95% confidence interval [95% CI], 54-81%) and as bothersome but tolerable by 12 patients (31%; 95% CI, 19-46%). Mean FiO2 returned to baseline within 2hours after FOB in 30 patients; the remaining 9 patients (23%; 95% CI, 13-38%) received ventilatory support intensification. Ease of execution was good or very good in 34 patients (87%; 95% CI, 73-94%), acceptable in 4 patients, and poor in 1 patient (persistent cough). CONCLUSION Sedation with remifentanil-TCI during FOB with prior failure under topical anaesthesia alone was effective and acceptably safe in non-intubated hypoxaemic thoracic surgery patients.

Non-Ventilator ICU-Acquired Pneumonia After Cardiothoracic Surgery: Accuracy of Diagnostic Tools and Outcomes

BACKGROUND: Non-ventilator ICU-acquired pneumonia after cardiothoracic surgery is challenging to diagnose, and little is known about its impact on patient outcomes. Here, our primary objective was to compare the sensitivity and specificity of cultures of 2 types of fiberoptic bronchoscopy (FOB) specimens: endotracheal aspirates (FOB-EA) and bronchoalveolar lavage fluid (FOB-BAL). The secondary objectives were to evaluate the sensitivity and specificity of spontaneous sputum cultures and of the modified Clinical Pulmonary Infection Score (CPIS) and to describe patient outcomes. METHODS: We conducted a prospective observational study of consecutive cardiothoracic surgery subjects with suspected non-ventilator ICU-acquired pneumonia. Using FOB-BAL cultures ≥104 cfu/mL as the reference standard, we evaluated the accuracy of FOB-EA ≥105 cfu/mL and spontaneous sputum ≥107 cfu/mL. On the day of FOB, we determined the modified CPIS. Mortality and antibiotic treatments were recorded. RESULTS: Of 105 subjects, 57 (54.3%) received a diagnosis of non-ventilator ICU-acquired pneumonia. FOB-EA cultures had 82% (95% CI 69–91%) sensitivity and 100% (95% CI 89–100%) specificity and were significantly less sensitive than FOB-BAL cultures (P < .004). Spontaneous sputum was obtained from one-third of subjects. Spontaneous sputum cultures had 82% (95% CI 56–95%) sensitivity and 94% (95% CI 68–100%) specificity and were non-significantly less sensitive than FOB-BAL (P = .061). A modified CPIS >6 had 42% (95% CI 29–56%) sensitivity and 87% (95% CI 74–95%) specificity for non-ventilator ICU-acquired pneumonia. Antibiotic therapy was stopped in all subjects without non-ventilator ICU-acquired pneumonia, after 1.6 ± 1.2 d, without deleterious effects. CONCLUSIONS: The modified CPIS has low diagnostic accuracy for non-ventilator ICU-acquired pneumonia. FOB-EA cultures perform less well than do FOB-BAL cultures for diagnosing non-ventilator ICU-acquired pneumonia. Spontaneous sputum is valuable when FOB cannot be performed but could be obtained in only a minority of subjects. When cultures are negative, antibiotic discontinuation is safe.