Background
In COVID-19 patients with severe acute respiratory distress syndrome (ARDS), the relatively preserved respiratory system compliance despite severe hypoxemia, with specific pulmonary ...vascular dysfunction, suggests a possible hemodynamic mechanism for VA/Q mismatch, as hypoxic vasoconstriction alteration. This study aimed to evaluate the capacity of inhaled nitric oxide (iNO)–almitrine combination to restore oxygenation in severe COVID-19 ARDS (C-ARDS) patients.
Methods
We conducted a monocentric preliminary pilot study in intubated patients with severe C-ARDS. Respiratory mechanics was assessed after a prone session. Then, patients received iNO (10 ppm) alone and in association with almitrine (10 μg/kg/min) during 30 min in each step. Echocardiographic and blood gases measurements were performed at baseline, during iNO alone, and iNO–almitrine combination. The primary endpoint was the variation of oxygenation (PaO
2
/FiO
2
ratio).
Results
Ten severe C-ARDS patients were assessed (7 males and 3 females), with a median age of 60 52–72 years. Combination of iNO and almitrine outperformed iNO alone for oxygenation improvement. The median of PaO
2
/FiO
2
ratio varied from 102 89–134 mmHg at baseline, to 124 108–146 mmHg after iNO (
p
= 0.13) and 180 132–206 mmHg after iNO and almitrine (
p
< 0.01). We found no correlation between the increase in oxygenation caused by iNO–almitrine combination and that caused by proning.
Conclusion
In this pilot study of severe C-ARDS patients, iNO–almitrine combination was associated with rapid and significant improvement of oxygenation. These findings highlight the role of pulmonary vascular function in COVID-19 pathophysiology.
Purpose
Although patients with SARS-CoV-2 infection have several risk factors for ventilator-associated lower respiratory tract infections (VA-LRTI), the reported incidence of hospital-acquired ...infections is low. We aimed to determine the relationship between SARS-CoV-2 pneumonia, as compared to influenza pneumonia or no viral infection, and the incidence of VA-LRTI.
Methods
Multicenter retrospective European cohort performed in 36 ICUs. All adult patients receiving invasive mechanical ventilation > 48 h were eligible if they had: SARS-CoV-2 pneumonia, influenza pneumonia, or no viral infection at ICU admission. VA-LRTI, including ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP), were diagnosed using clinical, radiological and quantitative microbiological criteria. All VA-LRTI were prospectively identified, and chest-X rays were analyzed by at least two physicians. Cumulative incidence of first episodes of VA-LRTI was estimated using the Kalbfleisch and Prentice method, and compared using Fine-and Gray models.
Results
1576 patients were included (568 in SARS-CoV-2, 482 in influenza, and 526 in no viral infection groups). VA-LRTI incidence was significantly higher in SARS-CoV-2 patients (287, 50.5%), as compared to influenza patients (146, 30.3%, adjusted sub hazard ratio (sHR) 1.60 (95% confidence interval (CI) 1.26 to 2.04)) or patients with no viral infection (133, 25.3%, adjusted sHR 1.7 (95% CI 1.2 to 2.39)). Gram-negative bacilli were responsible for a large proportion (82% to 89.7%) of VA-LRTI, mainly
Pseudomonas aeruginosa
, Enterobacter spp., and Klebsiella spp.
Conclusions
The incidence of VA-LRTI is significantly higher in patients with SARS-CoV-2 infection, as compared to patients with influenza pneumonia, or no viral infection after statistical adjustment, but residual confounding may still play a role in the effect estimates.
To evaluate independent factors associated with ACP, significant or marginally significant (p < 0.10) bivariate risk factors (using the above-mentioned tests) were examined using univariate and ...multivariable backward stepwise logistic regression analysis. SEE PDF Our study suggests that ACP is more prevalent in C-ARDS than previously reported in NC-ARDS, and is rather driven by pulmonary vascular obstruction in this group of patients than classical risk factors favoring vascular constriction/compression (hypoxemia, hypercapnia and driving pressure). ...ACP seems more frequent and more related to pulmonary embolism in C-ARDS as compared to NC-ARDS.
The approach for veno-arterial extracorporeal membrane oxygenation implantation (VA-ECMO) in patients with cardiogenic shock can be either surgical or percutaneous. Complete angio-guided percutaneous ...implantation and explantation could decrease vascular complications. We sought to describe the initial results of complete percutaneous angio-guided ECMO implantation and explantation using preclosing.
All consecutive patients who underwent peripheral femoro-femoral VA-ECMO percutaneous implantation for refractory cardiogenic shock or cardiac arrest were enrolled in a prospective registry (03/2018-12/2020). Percutaneous preclosing using two closing devices (Perclose ProGlide, Abbott) inserted before cannulation was used in both femoral artery and vein. Explantation was performed using a crossover technique under angiographic guidance. The occurrence of vascular complication was recorded.
Among the 56 patients who underwent percutaneous VA-ECMO implantation for cardiogenic shock or refractory cardiac arrest, 41 underwent preclosing. Femoral vessel cannulation was successful in all patients and total cannulation time was 20 (10-40) min. Weaning from ECMO was possible in 22/41 patients (54%) and 12 (29%) patients were alive at day 30. Significant vascular complications occurred in 2/41 patients. Percutaneous decannulation was performed in 20 patients with 19/20 technical success rate. All femoral arteries and veins were properly closed using the pre-closing devices without bleeding on the angiographic control except for one patient in whom surgical closure of the artery was required. No patient required transfusion for access related significant bleeding and no other vascular complication occurred. Furthermore, no groin infection was observed after full percutaneous implantation and removal of ECMO.
Emergent complete percutaneous angio-guided VA-ECMO implantation and explantation using pre-closing technique can be an attractive strategy in patients referred for refractory cardiogenic shock.
Background
Left atrial strain (LAS) is a measure of atrial wall deformation during cardiac cycle and reflects atrial contribution to cardiovascular performance. Pathophysiological significance of LAS ...in critically ill patients with hemodynamic instability has never been explored. This study aimed at describing LAS and its variation during volume expansion and to assess the relationship between LAS components and fluid responsiveness.
Methods
This prospective observational study was performed in a French ICU and included patients with acute circulatory failure, for whom the treating physician decided to proceed to volume expansion (rapid infusion of 500 mL of crystalloid solution). Trans-thoracic echocardiography was performed before and after the fluid infusion. LAS analysis was performed offline. Fluid responsiveness was defined as an increase in velocity-time integral (VTI) of left ventricular outflow tract ≥ 10%.
Results
Thirty-eight patients were included in the final analysis. Seventeen (45%) patients were fluid responders. LAS analysis had a good feasibility and reproducibility. Overall, LAS was markedly reduced in all its components, with values of 19 15 – 32, -9 -19 – -7 and − 9 -13 – -5 % for LAS reservoir (LASr), conduit (LAScd) and contraction (LASct), respectively. LASr, LAScd and LASct significantly increased during volume expansion in the entire population. Baseline value of LAS did not predict fluid responsiveness and the changes in LAS and VTI during volume expansion were not significantly correlated.
Conclusions
LAS is severely altered during acute circulatory failure. LAS components significantly increase during fluid administration, but cannot be used to predict or assess fluid responsiveness.
Hypoxemia is the main feature of COVID-19-related acute respiratory distress syndrome (C-ARDS), but its underlying mechanisms are debated, especially in patients with low respiratory system elastance ...(Ers). We assessed 60 critically ill patients hospitalized in our intensive care unit for C-ARDS. We used contrast transthoracic echocardiography to assess patent foramen ovale (PFO) shunt and transpulmonary bubble transit (TPBT). The median Ers was 32 cmH
2
O/L. PFO shunt was detected in six (10%) patients and TPBT in 12 (20%) patients. PFO shunt and TPBT were similar in patients with higher or lower Ers. In conclusion, PFO and TPBT do not seem to be the main drivers of hypoxemia in C-ARDS, especially in patients with lower Ers.
Abstract
Background
Microaspiration of gastric and oropharyngeal secretions is the main causative mechanism of ventilator-associated pneumonia (VAP). Transesophageal echocardiography (TEE) is a ...routine investigation tool in intensive care unit and could enhance microaspiration. This study aimed at evaluating the impact of TEE on microaspiration and VAP in intubated critically ill adult patients.
Methods
It is a four-center prospective observational study. Microaspiration biomarkers (pepsin and salivary amylase) concentrations were quantitatively measured on tracheal aspirates drawn before and after TEE. The primary endpoint was the percentage of patients with TEE-associated microaspiration, defined as: (1) ≥ 50% increase in biomarker concentration between pre-TEE and post-TEE samples, and (2) a significant post-TEE biomarker concentration (> 200 μg/L for pepsin and/or > 1685 IU/L for salivary amylase). Secondary endpoints included the development of VAP within three days after TEE and the evolution of tracheal cuff pressure throughout TEE.
Results
We enrolled 100 patients (35 females), with a median age of 64 (53–72) years. Of the 74 patients analyzed for biomarkers, 17 (23%) got TEE-associated microaspiration. However, overall, pepsin and salivary amylase levels were not significantly different between before and after TEE, with wide interindividual variability. VAP occurred in 19 patients (19%) within 3 days following TEE. VAP patients had a larger tracheal tube size and endured more attempts of TEE probe introduction than their counterparts but showed similar aspiration biomarker concentrations. TEE induced an increase in tracheal cuff pressure, especially during insertion and removal of the probe.
Conclusions
We could not find any association between TEE-associated microaspiration and the development of VAP during the three days following TEE in intubated critically ill patients. However, our study cannot formally rule out a role for TEE because of the high rate of VAP observed after TEE and the limitations of our methods.
Clinical manifestations of coronavirus disease 2019 in pregnant women, in contrast to previous outbreaks, seem to be similar to those of nonpregnant women. During severe acute respiratory syndrome ...(SARS), SARS influenza A, and Middle East respiratory syndrome outbreaks, an increased severity of disease among pregnant women was observed.
In some pregnant women, respiratory failure can occur and progress quickly to acute respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO) as a rescue therapy. Despite a lack of current guidelines on the use of ECMO in pregnant or postpartum women, this support therapy is an effective salvage therapy for patients with cardiac and/or respiratory failure, and is associated with favorable maternal and fetal outcomes. Herein, the authors report a case of severe COVID-19 disease in a pregnant patient after urgent cesarean delivery, who was treated successfully with ECMO during the postpartum. Extracorporeal membrane oxygenation should be considered early when conventional therapy is ineffective, and it is essential to refer to ECMO expert centers.
OBJECTIVES:Extracorporeal life support could be helpful for severe acute chest syndrome in adults sickle cell disease, because of the frequent hemodynamic compromise in this setting, including acute ...pulmonary vascular dysfunction and right ventricular failure. The aim of this study was to report the extracorporeal life support experience for severe acute chest syndrome in four referral centers in France.
DESIGN:The primary endpoint of this multicentric retrospective study was ICU survival of patients with severe acute chest syndrome managed with extracorporeal life support. Secondary endpoints included comparisons between survivors and nonsurvivors.
SETTING:We performed this study between January 2009 and July 2017 in four referral centers in France.
PATIENTS:We included adult patients (age > 18 yr) with sickle cell disease, admitted for severe acute chest syndrome and who required extracorporeal life support during the ICU stay.
INTERVENTIONS:The study was observational.
MEASUREMENTS AND MAIN RESULTS:Over the 8-year period, 22 patients with sickle cell disease required extracorporeal life support for severe acute chest syndrome, including 10 (45%) veno-venous and 12 (55%) veno-arterial extracorporeal life support. In-ICU mortality was high (73%). Nonsurvivors had a higher severity at extracorporeal life support implantation, as assessed by their Vasoactive-Inotrope Score and number of organ failures.
CONCLUSIONS:Our study shows that outcome is impaired in sickle cell disease patients receiving extracorporeal life support while in severe multiple organ failure. Further studies are needed to evaluate selection criteria in this setting.
Circulatory shock is a life-threatening condition responsible for inadequate tissue perfusion. The objectives of hemodynamic monitoring in this setting are multiple: identifying the mechanisms of ...shock (hypovolemic, distributive, cardiogenic, obstructive); choosing the adequate therapeutic intervention, and evaluating the patient’s response. Echocardiography is proposed as a first line tool for this assessment in the intensive care unit. As compared to trans-thoracic echocardiography (TTE), trans-esophageal echocardiography (TEE) offers a better echogenicity and is the best way to evaluate deep anatomic structures. The therapeutic implication of TEE leads to frequent changes in clinical management. It also allows depicting sources of inaccuracy of thermodilution-based hemodynamic monitoring. It is a semi invasive tool with a low rate of complications. The first step in the hemodynamic evaluation of shock is to characterize the mechanisms of circulatory failure among hypovolemia, vasoplegia, cardiac dysfunction, and obstruction. Echocardiographic evaluation includes evaluation of LV systolic and diastolic function, as well as RV function, pericardium, measure of stroke volume and cardiac output, and evaluation of hypovolemia and fluid responsiveness. TEE can be used as a semi-continuous monitoring tool and can be repeated before and after therapeutic interventions (vasopressors, inotropes, fluid therapy, specific treatment such as pericardial effusion evacuation) to evaluate efficacy and tolerance of therapeutic interventions. In conclusion, TEE plays an important role in the management of circulatory failure when TTE is not enough to answer to the questions, although it is not a continuous tool of monitoring. TEE results must be integrated in a global evaluation, the first step being clinical examination. Whether TEE-directed therapy and close hemodynamic monitoring of shock has an impact on outcome remains debated.
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