Highlights • Nocturnal hypercapnia may be present in daytime normocapnic neuromuscular patients. • Nocturnal hypercapnia seems to predict mechanical ventilation in follow-up. • Several cut-offs have ...been proposed to define nocturnal hypoventilation. • Peak TcCO2 should be the preferred criterion for nocturnal hypoventilation.
Abstract Background/objectives Muscular dystrophies are genetic muscle disorders, in which heart involvement and chronic respiratory impairment affect survival. Cardiac conduction disturbances ...require implantable cardiac pacemaker. Implantable defibrillators may also be necessary to prevent cardiac sudden death. The safety and risk of cardiac electronic devices' implantation are not known in patients with muscular dystrophy. We aimed to assess the risks related to cardiac implantable electronic devices (CIED) in muscular dystrophy patients ventilated by tracheostomy. Methods We reviewed all medical charts of neuromuscular patients and identified all CIED implantations of pacemakers (PM) or defibrillators (ICD) in patients ventilated using tracheostomy. Results Twelve device implantations were included, performed in 9 patients (5 DMD, 1 Becker muscular dystrophy and 3 DM1). Mean age was 39.9 years ± 13.0. All patients were wheel-chair bound and tracheotomized. Six pacemakers (PM) and 6 cardiac resynchronization (CRT) devices, including 2 defibrillators (CRT-D) were implanted. Following device implantation, two patients had a pneumothorax and one died from severe heart failure after an unsuccessful CRT implant attempt. Follow-up lasted up to 8 years (mean 2.6 ± 2.9 years), during which one patient presented a PM pocket infection, requiring PM explantation and epicardial reimplantation. Conclusion We found a high prevalence of early complications (16.6% pneumothorax) after CIED implantation and an acceptable long-term infectious risk (8.3%). These results highlight the feasibility of CIED implantation in tracheotomized patients with muscular dystrophies and the need for a particular caution in the management of these patients during invasive procedures. ClinicalTrials.gov (identifier: NCT02501083 ).
Abstract Purpose Hypocitrullinemia has been suggested to be a prognostic factor for patients in intensive care. The aim of this ancillary study of the Corticosteroids and Intensive Insulin Therapy ...for Septic Shock prospective study was to investigate plasma l -citrulline concentrations and its relationship with inflammation and digestive bacterial translocation in patients with septic shock multiorgan failure and without primary intestinal disease or chronic renal failure. Methods Sixteen adult patients were selected. They were studied on day (D) 0 at hours (H) 0, 6, 12, 18, and 24 and on D4 (H96). Selected plasma amino acids and proteins, proinflammatory (tumor necrosis factor α TNF- α ) and anti-inflammatory (interleukin IL 10) cytokine concentrations, and bacterial translocation were measured. Results Eight D14 survivors and 8 D14 nonsurvivors patients were studied. Citrulline was decreased on D0 (H0: 29 ± 10 vs nadir: 18 ± 6 μ mol/L; P < .05). The citrulline nadir was lower ( P < .01) in patients with digestive bacterial translocation than that in those without. Mean citrulline concentrations at H0 to H96 were not significantly different between survivors and nonsurvivors. In both groups, citrulline was significantly inversely correlated with C-reactive protein ( r2 = 0.10, P < .01) on D0. No significant correlations were found between citrulline and albumin, transthyretin, TNF- α , IL-10, or TNF- α /IL-10 ratio. Conclusions At the onset of septic shock, plasma citrulline decreases and varies inversely with C-reactive protein and is lower when digestive bacterial translocation occurs. This finding could reflect an early acute intestinal dysfunction, but measurement of citrulline concentration does not appear to be able to predict the patients' mortality.
Abstract Purpose The objective of this study is to record intensivists' beliefs on indications and modalities of ventilatory support in critically ill patients with septic shock. Methods The ...instrument is a 23-items questionnaire, sent to all members of the Systemic Inflammation and Sepsis section of the European Society of Intensive Care Medicine. Results A total of 186 intensivists from 30 countries completed the survey. For 95% of respondents, intubation should be performed in patients with neurologic or respiratory failure. There was much less consensus about cardiovascular failure as a reason for initiation of invasive mechanical ventilation. Among the 7 hemodynamic criteria proposed, none achieved strong agreement. Among respiratory criteria, hypoxemia, signs of respiratory distress, and cyanosis were the most strongly associated with the will to intubate. Among neurologic criteria, a Glasgow score lower than 8 was strongly associated with the will to intubate. Strikingly, 51% of respondents believed that invasive mechanical ventilation would worsen patients with septic shock, mainly through hemodynamic deterioration (70.4%). Conclusions This survey highlights the general belief that invasive mechanical ventilation may worsen hemodynamic status in patients with septic shock. There was general agreement with the mandatory need to initiate mechanical ventilation in patients with respiratory failure and coma, but with little respect to hemodynamic criteria.
Abstract Background : Myotonic muscular dystrophy type 1 (MMD1) is the most common form of adult MD, with a mean prevalence of 1 in 8000. Excessive daytime sleepiness (ie, hypersomnia) is a common ...complication of MMD1. Objective : The aim of this study was to evaluate the efficacy and tolerability of modafinil for the treatment of hypersomnia in adults with MMD1. Methods : This multicenter, prospective, randomized, double-blind, placebo-controlled study consisted of a prerandomization period (90 to 2 days before randomization) and a 4-week randomization period in which patients were assigned to receive either active treatment (modafinil 300 mg/d) or placebo. The study was conducted at 3 clinics in France between February 2000 and June 2002. Adult patients aged ≥18 years, with genetically proven MMD1, an Epworth Sleepiness Scale (ESS) score >10, and a mean latency to sleep onset ≤8 minutes measured by the Multiple Sleep Latency Test (MSLT) were eligible. The primary efficacy end point was the Maintenance of Wakefulness Test (MWT) score at 4 weeks. Secondary end points included the mean MSLT score and scores from the ESS, physician's assessment of the therapeutic effect and the patient's global self-assessment via visual analog scale, the 17-item Hamilton Depression Rating Scale, and the Short Form Health Survey (SF-36) quality-of-life assessment. Results : A total of 28 patients (15 men, 13 women; mean SD age, 40 12.7 years range, 18–69 years; 100% white; modafinil group, 13; placebo group, 15) completed the study without protocol violations. Of the 28 patients with MMD1 included in the analysis, 21 had adult-onset MMD1. At 4 weeks, the mean MWT score was 16.4 (3.3) minutes in the modafinil group and 15.8 (3.8) minutes in the placebo group ( P = NS). At the end of the randomization period, there were no significant between-group differences in any secondary outcome. A total of 8 patients (4 in each group) reported ≥1 adverse event, including digestive, neurologic, and skin symptoms. Weight loss was reported in 1 patient (2 kg). Conclusion : In this small study conducted in an adult population with MMD1 and a high prevalence of hyper-somnia, modafinil had no significant effects on daytime somnolence measured using objective MWTs.
The encephalopathy in sepsis Siami, Shidasp; Annane, Djillali; Sharshar, Tarek
Critical care clinics
24, Številka:
1
Journal Article
Recenzirano
Brain dysfunction is a severe complication of sepsis with an incidence ranging from 9% to 71% that is associated with increased morbidity and mortality. Its diagnosis relies mainly on neurologic ...examination with clinical manifestations ranging from confusion to coma. An electroencephalogram, somatosensory evoked potentials, and measurement of plasma S-100b protein and neuron-specific enolase can be useful for the detection of brain dysfunction. Brain MRI can identify brain lesions such as cerebral infarction, posterior reversible encephalopathy syndrome, and leukoencephalopathy. The mechanism of sepsis-associated encephalopathy involves inflammatory and non-inflammatory processes that affect endothelial cells, glial cells, and neurons and induce blood-brain barrier breakdown, derangements of intracellular metabolism, and cell death. Specific treatments for sepsis-associated encephalopathy need to be developed. Currently, treatment is mainly the management of sepsis.
To perform a systematic review and meta-analysis to assess the efficacy and safety of corticosteroids in patients with sepsis.
We searched PubMed, Embase, and the Cochrane Library, up to January 10, ...2023.
We included randomized controlled trials (RCTs) comparing corticosteroids with placebo or standard care with sepsis.
The critical outcomes of interest included mortality, shock reversal, length of stay in the ICU, and adverse events.
We performed both a pairwise and dose-response meta-analysis to evaluate the effect of different corticosteroid doses on outcomes. We used Grading of Recommendations Assessment, Development and Evaluation to assess certainty in pooled estimates.
We included 45 RCTs involving 9563 patients. Corticosteroids probably reduce short-term mortality (risk ratio RR, 0.93; 95% CI, 0.88-0.99; moderate certainty) and increase shock reversal at 7 days (RR, 1.24; 95% CI, 1.11-1.38; high certainty). Corticosteroids may have no important effect on duration of ICU stay (mean difference, -0.6 fewer days; 95% CI, 1.48 fewer to 0.27 more; low certainty); however, probably increase the risk of hyperglycemia (RR, 1.13; 95% CI, 1.08-1.18; moderate certainty) and hypernatremia (RR, 1.64; 95% CI, 1.32-2.03; moderate certainty) and may increase the risk of neuromuscular weakness (RR, 1.21; 95% CI, 1.01-1.45; low certainty). The dose-response analysis showed a reduction in mortality with corticosteroids with optimal dosing of approximately 260 mg/d of hydrocortisone (RR, 0.90; 95% CI, 0.83-0.98) or equivalent.
We found that corticosteroids may reduce mortality and increase shock reversal but they may also increase the risk of hyperglycemia, hypernatremia, and neuromuscular weakness. The dose-response analysis indicates optimal dosing is around 260 mg/d of hydrocortisone or equivalent.
Experimental and clinical evidence show a strong association between dysregulated systemic inflammation and progression of acute respiratory distress syndrome (ARDS). This article reviews eight ...controlled studies evaluating corticosteroid treatment initiated before day 14 of ARDS. Available data provide a consistent strong level of evidence for improving outcomes. Treatment was also associated with a markedly reduced risk of death. This low-cost highly effective therapy is well-known, and has a low-risk profile when secondary prevention measures are implemented. The authors recommend prolonged methylprednisolone at 1 mg/kg/d initially in early ARDS, increasing to 2 mg/kg/d after 7 to 9 days of no improvement.
We postulate that corticosteroid-related side effects in critically ill patients are similar across sepsis, acute respiratory distress syndrome (ARDS), and community-acquired pneumonia (CAP). By ...pooling data across all trials that have examined corticosteroids in these three acute conditions, we aim to examine the side effects of corticosteroid use in critical illness.
We performed a comprehensive search of MEDLINE, Embase, Centers for Disease Control and Prevention library of COVID research, CINAHL, and Cochrane center for trials.
We included randomized controlled trials (RCTs) that compared corticosteroids to no corticosteroids or placebo in patients with sepsis, ARDS, and CAP.
We summarized data addressing the most described side effects of corticosteroid use in critical care: gastrointestinal bleeding, hyperglycemia, hypernatremia, superinfections/secondary infections, neuropsychiatric effects, and neuromuscular weakness.
We included 47 RCTs (
= 13,893 patients). Corticosteroids probably have no effect on gastrointestinal bleeding (relative risk RR, 1.08; 95% CI, 0.87-1.34; absolute risk increase ARI, 0.3%; moderate certainty) or secondary infections (RR, 0.97; 95% CI, 0.89-1.05; absolute risk reduction, 0.5%; moderate certainty) and may have no effect on neuromuscular weakness (RR, 1.22; 95% CI, 1.03-1.45; ARI, 1.4%; low certainty) or neuropsychiatric events (RR, 1.19; 95% CI, 0.82-1.74; ARI, 0.5%; low certainty). Conversely, they increase the risk of hyperglycemia (RR, 1.21; 95% CI, 1.11-1.31; ARI, 5.4%; high certainty) and probably increase the risk of hypernatremia (RR, 1.59; 95% CI, 1.29-1.96; ARI, 2.3%; moderate certainty).
In ARDS, sepsis, and CAP, corticosteroids are associated with hyperglycemia and probably with hypernatremia but likely have no effect on gastrointestinal bleeding or secondary infections. More data examining effects of corticosteroids, particularly on neuropsychiatric outcomes and neuromuscular weakness, would clarify the safety of this class of drugs in critical illness.
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