Rationale
Increased right ventricle (RV) afterload during acute respiratory distress syndrome (ARDS) may induce acute cor pulmonale (ACP).
Objectives
To determine the prevalence and prognosis of ACP ...and build a clinical risk score for the early detection of ACP.
Methods
This was a prospective study in which 752 patients with moderate-to-severe ARDS receiving protective ventilation were assessed using transesophageal echocardiography in 11 intensive care units. The study cohort was randomly split in a derivation (
n
= 502) and a validation (
n
= 250) cohort.
Measurements and main results
ACP was defined as septal dyskinesia with a dilated RV end-diastolic RV/left ventricle (LV) area ratio >0.6 (≥1 for severe dilatation). ACP was found in 164 of the 752 patients (prevalence of 22 %; 95 % confidence interval 19–25 %). In the derivation cohort, the ACP risk score included four variables pneumonia as a cause of ARDS, driving pressure ≥18 cm H
2
O, arterial oxygen partial pressure to fractional inspired oxygen (PaO
2
/FiO
2
) ratio <150 mmHg, and arterial carbon dioxide partial pressure ≥48 mmHg. The ACP risk score had a reasonable discrimination and a good calibration. Hospital mortality did not differ between patients with or without ACP, but it was significantly higher in patients with severe ACP than in the other patients 31/54 (57 %) vs. 291/698 (42 %);
p
= 0.03. Independent risk factors for hospital mortality included severe ACP along with male gender, age, SAPS II, shock, PaO
2
/FiO
2
ratio, respiratory rate, and driving pressure, while prone position was protective.
Conclusions
We report a 22 % prevalence of ACP and a poor outcome of severe ACP. We propose a simple clinical risk score for early identification of ACP that could trigger specific therapeutic strategies to reduce RV afterload.
Aim
To address the paucity of data on the characteristics, outcome and temporal trends in mortality of cardiogenic shock (CS) patients admitted to intensive care units (ICUs) we examined key ...features, variations in mortality from CS, and predictors of death in ICU patients over the past 15 years.
Methods and results
From the 1997–2012 database of the Collège des Utilisateurs de Bases de données en Réanimation (CUB‐Réa) that prospectively collects data from ICUs in the greater Paris area, we determined temporal trends in the incidence of CS, patient outcomes Crude and Simplified Acute Physiology Score (SAPS)‐II Standardized Mortality and predictors of in‐ICU mortality. Of the 316 905 ICU admissions, 19 416 (6.1%) exhibited CS, with incidence increasing from 4.1% to 7.7% (P < 0.001). Over time, the age of admitted patients decreased by 2.7 years 95% confidence interval (CI), −2.0 to −3.4 and SAPS‐II increased by 5.8% (95% CI 4.8–6.8) from 58.7 ± 25.3 to 64.5 ± 23.3 (P < 0.001). Crude in‐ICU mortality declined from 50% to 45% (−5.6%; 95% CI −7.7 to −3.5) as SAPS‐II Standardized ICU mortality rates decreased from 56.5% to 44.2% (P < 0.001). A more recent time‐period was an independent correlate of decreased mortality in multivariate analyses. The decrease in mortality rate was more marked in patients with decompensated heart failure, cardiac arrest, or acute myocardial infarction.
Conclusions
Patients with CS represent a greater proportion of patients admitted to ICUs over the past 15 years, having become younger but more critically ill. Although their mortality has decreased, suggesting improved overall patient management, it remains particularly high, warranting further research specifically focused on this population.
There is an extensive body of literature focused on sepsis-induced myocardial dysfunction, but results are conflicting and no objective definition of septic cardiomyopathy (SCM) has been established. ...SCM may be defined as a sepsis-associated acute syndrome of non-ischemic cardiac dysfunction with systolic and/or diastolic left ventricular (LV) dysfunction and/or right ventricular dysfunction. Physicians should consider this diagnosis in patients with sepsis-associated organ dysfunction, and particularly in cases of septic shock that require vasopressors. Echocardiography is currently the gold standard for diagnosis of SCM. Left ventricular ejection fraction is the most common parameter used to describe LV function in the literature, but its dependence on loading conditions, particularly afterload, limits its use as a measure of intrinsic myocardial contractility. Therefore, repeated echocardiography evaluation is mandatory. Evaluation of global longitudinal strain (GLS) may be more sensitive and specific for SCM than LV ejection fraction (LVEF). Standard management includes etiological treatment, adapted fluid resuscitation, use of vasopressors, and monitoring. Use of inotropes remains uncertain, and heart rate control could be an option in some patients.
Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired ...weakness on extubation failure and the relation between limb weakness and cough strength.
A secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-not-reintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semi-quantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation.
Among 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission.
ICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.
Anticoagulants are widely used but can lead to iatrogenic events such as bleeding. Limited data exists regarding the characteristics and management of patients admitted to intensive care units (ICU) ...for severe anticoagulant-related extracranial bleeding.
A retrospective observational study was conducted in five French ICUs. From January 2007 to December 2018, all patients aged over 18 years admitted to ICU for extracranial bleeding while receiving therapeutic anticoagulation were included.
486 patients were included, mainly male (61%) with an average age of 73 ± 13 years. Most patients had comorbidities, including hypertension (68%), heart disease (49%) and diabetes (33%). Patients were treated by vitamin K antagonists (VKA, 54%), heparins (25%) and direct oral anticoagulants (DOAC, 7%). The incidence of patients admitted to ICU for anticoagulant-related bleeding increased from 3.2/1000 admissions in 2007 to 5.8/1000 in 2018. This increase was particularly high for DOAC class. Upon admission, patients exhibited severe organ failure, as evidenced by a high SOFA score (7 ± 4) and requirement for organ support therapies such as vasopressors (31.5%) and invasive mechanical ventilation (34%). Adherence to guidelines for the specific treatment of anticoagulant-related bleeding was generally low. ICU mortality was 27%. In multivariate analysis, five factors were independently associated with mortality: chronic hypertension, need for vasopressors, impaired consciousness, hyperlactatemia and prolonged aPTT > 1.2.
Anticoagulant-related extracranial bleeding requiring ICU admission is a serious complication responsible for organ failure and significant mortality. Its incidence is rising. The therapeutic management is suboptimal and could be improved by educational programs.
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.
Background
Critical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ...ventilation (MV) and higher mortality. CIRCI may alter cardiac and vascular functions. Weaning-induced pulmonary oedema (WiPO) is a major mechanism of weaning failure. The aim of this study was to evaluate the role of CIRCI in patients with difficult ventilator weaning and its possible relation with WiPO.
Methods
This is a prospective study conducted in the intensive care of a university hospital in France. Patients under MV for more than 24 h, meeting weaning criteria and having failed the first spontaneous breathing trial (SBT) underwent a corticotropin stimulation test, with assessment of total blood cortisol levels immediately before (
T
0
) 0.25 mg iv of tetracosactrin and 30 and 60 min afterward. Δ
max
was defined as the difference between the maximal value after the test and
T
0
. CIRCI was defined as
T
0
< 10 μg/dL (276 nmol/L) and/or Δ
max
< 9 μg/dL (248 nmol/L) and inadequate adrenal reserve as Δ
max
< 9 μg/dL. Biomarkers (natriuretic peptide and protidemia) sampling and echocardiograms were performed during the second SBT and were used to diagnose WiPO, which was defined according to two definitions (one liberal and one conservative) derived from recent publications on the topic. Successful extubation was defined as patient alive without reintubation 7 days after extubation. A competing risk analysis was used to assess extubation failure and mortality.
Results
Seventy-six consecutive patients (63 ± 14 years; 49 men) with difficult weaning were enrolled. CIRCI and inadequate adrenal reserve occurred in 25 (33%) and 17 (22%) patients, respectively. The probability of successful extubation was significantly decreased in patients with CIRCI or inadequate adrenal reserve, as compared to their counterparts, and this association persisted after adjustment on severity (SOFA score at first SBT). WiPO occurred in 44 (58%) and 8 (11%) patients, according to the liberal and conservative definition, respectively. WiPO was not associated with CIRCI nor with inadequate adrenal reserve.
Conclusion
CIRCI was common during difficult weaning and was associated with its prolongation. We did not find a significant association between CIRCI and WiPO.
Background
The medical workforce has been feminized for the last two decades worldwide. Nonetheless, women remain under-represented among intensivists. We conducted a survey among French women ...intensivists to assess their professional and personal quality of life and their perception of potential gender discrimination at work.
Methods
We conducted an observational descriptive study by sending a survey, designed by the group FEMMIR (FEmmes Médecins en Médecine Intensive Réanimation), to women intensivists in France, using primarily the Société de Réanimation de Langue Française (SRLF) mailing list. The questionnaire was also available online between September 2019 and January 2020 and women intensivists were encouraged to answer through email reminders. It pertained to five main domains, including demographic characteristics, work position, workload and clinical/research activities, self-fulfillment scale, perceived discrimination at work and suggested measures to implement.
Results
Three hundred and seventy-one women responded to the questionnaire, among whom 16% had an academic position. Being a woman intensivist and pregnancy were both considered to increase difficulties in careers’ advancement by 31% and 73% of the respondents, respectively. Almost half of the respondents (46%) quoted their quality of life equal to or lower than 6 on a scale varying from 1 (very bad quality of life) to 10 (excellent quality of life). They were 52% to feel an imbalance between their personal and professional life at the cost of their personal life. Gender discrimination has been experienced by 55% of the respondents while 37% confided having already been subject of bullying or harassment. Opportunities to adjust their work timetable including part-time work, better considerations for pregnant women including increasing the number of intensivists and the systematic replacement during maternity leave, and the respect of the law regarding the paternity leave were suggested as key measures to enable better professional and personal accomplishment by women intensivists.
Conclusion
In this first large French survey in women intensivists, we pointed out issues felt by women intensivists that included an imbalance between professional and personal life, a perceived loss of opportunity due to the fact of being a woman, frequent reported bullying or harassment and a lack of consideration of the needs related to pregnancy and motherhood.
Once the parity will be reached and sustained, this temporary measure will end. * All peer review journals should annually publish percentages of women members in their editorial board, of women who ...have submitted/published a paper as a first or senior author and of women who have reviewed a submitted manuscript. Raising awareness on those numbers can lead to substantial changes. * National and international conferences should announce the percentage of women speakers and chairs on their program. * National and international societies of Intensive Care should also announce the rate of women among their members, their board and committees and adopt policies to reach gender balance and use quotas as well. The improvement of numbers and balanced ratios could enable more profound changes, which would improve women doctors’ sense of belonging and inclusion: * Work conditions to allow personal and professional women fulfillment would change.
Legionnaires' disease (LD) is an important cause of community-acquired pneumonia with high mortality rates in the most severe cases.
To evaluate the effect of antimicrobial strategy on ICU mortality.
...Retrospective, observational study including patients admitted to 10 ICUs for severe community-acquired LD over a 10 year period (2005-15) and receiving an active therapy within 48 h of admission . Patients were stratified according to the antibiotic strategy administered: (i) fluoroquinolone-based versus non-fluoroquinolone-based therapy; and (ii) monotherapy versus combination therapy. The primary endpoint was in-ICU mortality. A multivariable Cox model and propensity score analyses were used.
Two hundred and eleven patients with severe LD were included. A fluoroquinolone-based and a combination therapy were administered to 159 (75%) and 123 (58%) patients, respectively. One hundred and forty-six patients (69%) developed acute respiratory distress syndrome and 54 (26%) died in the ICU. In-ICU mortality was lower in the fluoroquinolone-based than in the non-fluoroquinolone-based group (21% versus 39%, P = 0.01), and in the combination therapy than in the monotherapy group (20% versus 34%, P = 0.02). In multivariable analysis, a fluoroquinolone-based therapy, but not a combination therapy, was associated with a reduced risk of mortality HR = 0.41, 95% CI 0.19-0.89; P = 0.02.
Patients with severe LD receiving a fluoroquinolone-based antimicrobial regimen in the early course of management had a lower in-ICU mortality, which persisted after adjusting for significant covariates.
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