Background
Precision medicine risk stratification is desperately needed to both avoid systemic antifungals treatment delay and over prescription in the critically ill with risk factors. The aim of ...the present study was to explore the combination of host immunoparalysis biomarker (monocyte human leukocyte antigen-DR expression (mHLA-DR)) and Candida sp wall biomarker β-
d
-glucan in risk stratifying patients for secondary invasive Candida infection (IC).
Methods
Prospective observational study. Two intensive care units (ICU). All consecutive non-immunocompromised septic shock patients. Serial blood samples (
n
= 286) were collected at day 0, 2 and 7 and mHLA-DR and β-
d
-glucan were then retrospectively assayed after discharge. Secondary invasive Candida sp infection occurrence was then followed at clinicians’ discretion.
Results
Fifty patients were included, 42 (84%) had a Candida score equal or greater than 3 and 10 patients developed a secondary invasive Candida sp infection. ICU admission mHLA-DR expression and β-
d
-glucan (BDG) failed to predict secondary invasive Candida sp infection. Time-dependent cause-specific hazard ratio of IC was 6.56 1.24–34.61 for mHLA-DR < 5000 Ab/c and 5.25 0.47–58.9 for BDG > 350 pg/mL. Predictive negative value of mHLA-DR > 5000 Ab/c and BDG > 350 pg/mL combination at day 7 was 81% 95% CI 70–92.
Conclusions
This study suggests that mHLA-DR may help predicting IC in high-risk patients with septic shock. The added value of BDG and other fungal tests should be regarded according to the host immune function markers.
Purpose
High-flow nasal cannula oxygen (HFNC) has the potential to provide apnoeic oxygenation. We decided to assess in a proof-of-concept study whether the addition of HFNC to non-invasive ...ventilation (NIV) could reduce oxygen desaturation during intubation, compared with NIV alone for preoxygenation, in severely hypoxaemic intensive care unit (ICU) patients with respiratory failure.
Methods
We conducted a randomised, controlled, single-centre trial with assessor-blinded outcome assessment in patients admitted to the ICU. Hypoxaemic patients requiring orotracheal intubation for respiratory failure were randomised to receive preoxygenation using HFNC flow = 60 L/min, fraction of inspired oxygen (FiO
2
) = 100 % combined with NIV (pressure support = 10 cmH
2
O, positive end-expiratory pressure = 5 cmH
2
O, FiO
2
= 100 %) in the intervention group or NIV alone in the reference group prior to intubation. The primary outcome was the lowest oxygen saturation (SpO
2
) during the intubation procedure. Secondary outcomes were intubation-related complications and ICU mortality.
Results
Between July 2015 and February 2016, we randomly assigned 25 and 24 patients to the intervention and reference groups, respectively. In both groups the main reasons for respiratory failure were pneumonia and ARDS. During the intubation procedure, the lowest SpO
2
values were significantly higher in the intervention group than in the reference group 100 (95–100) % vs. 96 (92–99) %,
p
= 0.029. After exclusion of two patients from analysis for protocol violation, no (0 %) patients in the intervention group and five (21 %) patients in the reference group had SpO
2
below 80 % (
p
= 0.050). We recorded no significant difference between the groups in intubation-related complications or ICU mortality.
Conclusions
A novel strategy for preoxygenation in hypoxaemic patients, adding HFNC for apnoeic oxygenation to NIV prior to orotracheal intubation, may be more effective in reducing the severity of oxygen desaturation than the reference method using NIV alone.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Purpose
Single studies of video laryngoscopy (VL) use for airway management in intensive care unit (ICU) patients have produced controversial findings. The aim of this study was to critically review ...the literature to investigate whether VL reduces difficult orotracheal intubation (OTI) rate, first-attempt success, and complications related to intubation in ICU patients, compared to standard therapy, defined as direct laryngoscopy (DL).
Methods
We performed a systematic review and meta-analysis of randomized controlled trials, as well as prospective and retrospective observational studies, by searching PubMed, EMBASE, and bibliographies of articles retrieved. We screened for relevant studies that enrolled adults in whom the trachea was intubated in the ICU and compared VL to DL. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis. We generated pooled odd ratios (OR) across studies. The primary outcome measure was difficult OTI. The secondary outcomes were first-attempt success, Cormack 3/4 grades, and complications related to intubation (severe hypoxemia, severe cardiovascular collapse, airway injury, esophageal intubation).
Results
Nine trials with a total of 2,133 participants (1,067 in DL and 1,066 in VL) were included in the current analysis. Compared to DL, VL reduced the risk of difficult OTI OR 0.29 (95 % confidence interval (CI) 0.20–0.44,
p
< 0.001), Cormack 3/4 grades OR 0.26 (95 % CI 0.17–0.41,
p
< 0.001), and esophageal intubation 0.14 (95 % CI 0.02–0.81,
p
= 0.03) and increased the first-attempt success OR 2.07 (95 % CI 1.35–3.16,
p
< 0.001). No statistically significant difference was found for severe hypoxemia, severe cardiovascular collapse or airway injury.
Conclusions
These results suggest that VL could be useful in airway management of ICU patients.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Acute acidaemia is frequently observed during critical illness. Sodium bicarbonate infusion for the treatment of severe metabolic acidaemia is a possible treatment option but remains controversial, ...as no studies to date have examined its effect on clinical outcomes. Therefore, we aimed to evaluate whether sodium bicarbonate infusion would improve these outcomes in critically ill patients.
We did a multicentre, open-label, randomised controlled, phase 3 trial. Local investigators screened eligible patients from 26 intensive care units (ICUs) in France. We included adult patients (aged ≥18 years) who were admitted within 48 h to the ICU with severe acidaemia (pH ≤7·20, PaCO2 ≤45 mm Hg, and sodium bicarbonate concentration ≤20 mmol/L) and with a total Sequential Organ Failure Assessment score of 4 or more or an arterial lactate concentration of 2 mmol/L or more. We randomly assigned patients (1:1), by stratified randomisation with minimisation via a restricted web platform, to receive either no sodium bicarbonate (control group) or 4·2% of intravenous sodium bicarbonate infusion (bicarbonate group) to maintain the arterial pH above 7·30. Our protocol recommended that the volume of each infusion should be within the range of 125–250 mL in 30 min, with a maximum of 1000 mL within 24 h after inclusion. Randomisation criteria were stratified among three prespecified strata: age, sepsis status, and the Acute Kidney Injury Network (AKIN) score. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7. All analyses were done on data from the intention-to-treat population, which included all patients who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02476253.
Between May 5, 2015, and May 7, 2017, we enrolled 389 patients into the intention-to-treat analysis in the overall population (194 in the control group and 195 in the bicarbonate group). The primary outcome occurred in 138 (71%) of 194 patients in the control group and 128 (66%) of 195 in the bicarbonate group (absolute difference estimate −5·5%, 95% CI −15·2 to 4·2; p=0·24). The Kaplan-Meier method estimate of the probability of survival at day 28 between the control group and bicarbonate group was not significant (46% 95% CI 40–54 vs 55% 49–63; p=0·09. In the prespecified AKIN stratum of patients with a score of 2 or 3, the Kaplan-Meier method estimate of survival by day 28 between the control group and bicarbonate group was significant (37% 95% CI 28–48 vs 54% 45–65; p=0·0283). Metabolic alkalosis, hypernatraemia, and hypocalcaemia were observed more frequently in the bicarbonate group than in the control group, with no life-threatening complications reported.
In patients with severe metabolic acidaemia, sodium bicarbonate had no effect on the primary composite outcome. However, sodium bicarbonate decreased the primary composite outcome and day 28 mortality in the a-priori defined stratum of patients with acute kidney injury.
French Ministry of Health and the Société Française d'Anesthésie Réanimation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
BACKGROUND:Diaphragm and psoas are affected during sepsis in animal models. Whether diaphragm or limb muscle is preferentially affected during sepsis in the critically ill remains unclear.
...METHODS:Retrospective secondary analysis study including 40 patients, comparing control (n = 17) and critically ill patients, with (n = 14) or without sepsis (n = 9). Diaphragm volume, psoas volume, and cross-sectional area of the skeletal muscles at the third lumbar vertebra were measured during intensive care unit (ICU) stay using tridimensional computed tomography scan volumetry. Diaphragm strength was evaluated using magnetic phrenic nerve stimulation. The primary endpoint was the comparison between diaphragm and peripheral muscle volume kinetics during the ICU stay among critically ill patients, with or without sepsis.
RESULTS:Upon ICU admission, neither diaphragm nor psoas muscle volumes were significantly different between critically ill and control patients (163 ± 53 cm vs. 197 ± 82 cm for the diaphragm, P = 0.36, and 272 ± 116 cm vs. to 329 ± 166 cm for the psoas, P = 0.31). Twenty-five (15 to 36) days after admission, diaphragm volume decreased by 11 ± 13% in nonseptic and by 27 ± 12% in septic patients, P = 0.01. Psoas volume decreased by 11 ± 10% in nonseptic and by 19 ± 13% in septic patients, P = 0.09. Upon ICU admission, diaphragm strength was correlated with diaphragm volume and was lower in septic (6.2 cm H2O 5.6 to 9.3) than that in nonseptic patients (13.2 cm H2O 12.3 to 15.6), P = 0.01.
CONCLUSIONS:During the ICU stay, both diaphragm and psoas volumes decreased. In septic patients, the authors report for the first time in humans preferential diaphragm atrophy compared with peripheral muscles.
When compared with VenturiMask after extubation, high-flow nasal oxygen provides physiological advantages.
To establish whether high-flow oxygen prevents endotracheal reintubation in hypoxemic ...patients after extubation, compared with VenturiMask.
In this multicenter randomized trial, 494 patients exhibiting Pa
:Fi
ratio ⩽ 300 mm Hg after extubation were randomly assigned to receive high-flow or VenturiMask oxygen, with the possibility to apply rescue noninvasive ventilation before reintubation. High-flow use in the VenturiMask group was not permitted.
The primary outcome was the rate of reintubation within 72 hours according to predefined criteria, which were validated
by an independent adjudication committee. Main secondary outcomes included reintubation rate at 28 days and the need for rescue noninvasive ventilation according to predefined criteria. After intubation criteria validation (
= 492 patients), 32 patients (13%) in the high-flow group and 27 patients (11%) in the VenturiMask group required reintubation at 72 hours (unadjusted odds ratio, 1.26 95% confidence interval (CI), 0.70-2.26;
= 0.49). At 28 days, the rate of reintubation was 21% in the high-flow group and 23% in the VenturiMask group (adjusted hazard ratio, 0.89 95% CI, 0.60-1.31;
= 0.55). The need for rescue noninvasive ventilation was significantly lower in the high-flow group than in the VenturiMask group: at 72 hours, 8% versus 17% (adjusted hazard ratio, 0.39 95% CI, 0.22-0.71;
= 0.002) and at 28 days, 12% versus 21% (adjusted hazard ratio, 0.52 95% CI, 0.32-0.83;
= 0.007).
Reintubation rate did not significantly differ between patients treated with VenturiMask or high-flow oxygen after extubation. High-flow oxygen yielded less frequent use of rescue noninvasive ventilation. Clinical trial registered with www.clinicaltrials.gov (NCT02107183).
OBJECTIVES:To determine the short- and long-term mortality of obese ICU patients following medical as opposed to surgical admission and the relation between obesity and mortality.
...DESIGN:Retrospective analysis of prospectively collected data, using a propensity score–matched analysis of patients with medical or surgical admission.
SETTING:One French mixed medical-surgical ICU.
PATIENTS:Critically ill obese patients (body mass index ≥ 30 kg/m) and nonobese patients admitted during a 14-year period.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:Seven-hundred ninety-one obese patients and 4,644 nonobese patients were included, 338 (43%) and 2,367 (51%) medical and 453 (57%) and 2,277 (49%) surgical obese and nonobese patients, respectively. Mortality was significantly higher in medical than in surgical obese patients in ICU (25% vs 12%; p < 0.001) and up to 365 days (36% vs 18%; p < 0.001) post ICU admission. One-to-one propensity score matching generated 260 pairs with well-balanced baseline characteristics. After matching on propensity score, mortality was still significantly higher in medical patients both in the ICU (21% vs 13%; p = 0.03) and up to 365 days (30% vs 20%; p = 0.01) post ICU admission. Obesity was not significantly associated with mortality both in univariate analysis (140 obese patients 15% in the dead group vs 651 14% in the alive group; p = 0.72) and multivariate analysis (odds ratio, 1.09 95% CI, 0.86–1.38; p = 0.49) after adjustment for Simplified Acute Physiology Score II, age, category of admission, history of cardiac disease, and history of respiratory disease.
CONCLUSIONS:After careful matching, the data suggest that ICU mortality in obese population was higher in the medical group than in the surgical group and remains significantly higher 365 days post ICU admission.
Purpose
Airway management in intensive care unit (ICU) patients is challenging. The main objective of this study was to compare the incidence of difficult laryngoscopy and/or difficult intubation ...between a combo videolaryngoscope and the standard Macintosh laryngoscope in critically ill patients.
Methods
In the context of the implementation of a quality-improvement process for airway management, we performed a prospective interventional monocenter before–after study which evaluated a new combo videolaryngoscope. The primary outcome was the incidence of difficult laryngoscopy (defined by Cormack grade 3–4) and/or difficult intubation (more than two attempts). The secondary outcomes were the severe life-threatening complications related to intubation in ICU and the rate of difficult intubation in cases of predicted difficult intubation evaluated by a specific score (MACOCHA score ≥3).
Results
Two hundred and ten non-selected consecutive intubation procedures were included, 140 in the standard laryngoscope group and 70 in the combo videolaryngoscope group. The incidence of difficult laryngoscopy and/or difficult intubation was 16 % in the laryngoscope group vs. 4 % in the combo videolaryngoscope group (
p
= 0.01). The severe life-threatening complications related to intubation did not differ between groups (16 vs. 14 %,
p
= 0.79). Among the 32 patients with a MACOCHA score ≥3, there were significantly more patients with difficult intubation in the standard laryngoscope group in comparison to the combo videolaryngoscope group 12/23 (57 %) vs. 0/9 (0 %),
p
< 0.01.
Conclusions
The systematic use of a combo videolaryngoscope in ICU was associated with a decreased incidence of difficult laryngoscopy and/or difficult intubation.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Purpose
Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our ...study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order.
Methods
Prospective observational cohort study in all patients who received NIV for acute respiratory failure in 54 ICUs in France and Belgium, in 2010/2011.
Results
Goals of care, comfort, and vital status were assessed daily. On day 90, a telephone interview with patients and relatives recorded health-related quality of life (HRQOL), posttraumatic stress disorder-related symptoms, and symptoms of anxiety and depression. Post-ICU burden was compared between DNI patients and patients receiving NIV with no treatment-limitation decisions (TLD). Of 780 NIV patients, 574 received NIV with no TLD, and 134 had DNI orders. Hospital mortality was 44 % in DNI patients and 12 % in the no-TLD group. Mortality in the DNI group was lowest in COPD patients compared to other patients in the DNI group (34 vs. 51 %,
P
= 0.01). In the DNI group, HRQOL showed no significant decline on day 90 compared to baseline; day-90 data of patients and relatives did not differ from those in the no-TLD group.
Conclusions
Do-not-intubate status was present among one-fifth of ICU patients who received NIV. DNI patients who were alive on day 90 experienced no decrease in HRQOL compared to baseline. The prevalences of anxiety, depression, and PTSD-related symptoms in these patients and their relatives were similar to those seen after NIV was used as part of full-code management (clinicaltrial.govNCT01449331).
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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