Background
Coagulopathy is a common abnormality in patients with COVID‐19. However, the exact incidence of venous thromboembolic event is unknown in anticoagulated, severe COVID‐19 patients.
...Objectives
Systematic assessment of venous thromboembolism (VTE) using complete duplex ultrasound (CDU) in anticoagulated COVID‐19 patients.
Patients and methods
We performed a retrospective study in 2 French intensive care units (ICU) where CDU is performed as a standard of care. A CDU from thigh to ankle at selected sites with Doppler waveforms and images was performed early during ICU stay in patients admitted with COVID‐19. Anticoagulation dose was left to the discretion of the treating physician based on the individual risk of thrombosis. Patients were classified as treated with prophylactic anticoagulation or therapeutic anticoagulation. Pulmonary embolism was systematically searched in patients with persistent hypoxemia or secondary deterioration.
Results
From March 19 to April 11, 2020, 26 consecutive patients with severe COVID‐19 were screened for VTE. Eight patients (31%) were treated with prophylactic anticoagulation, whereas 18 patients (69%) were treated with therapeutic anticoagulation. The overall rate of VTE in patients was 69%. The proportion of VTE was significantly higher in patients treated with prophylactic anticoagulation when compared with the other group (100% vs 56%, respectively, P = .03). Surprisingly, we found a high rate of thromboembolic events in COVID‐19 patients treated with therapeutic anticoagulation, with 56% of VTE and 6 pulmonary embolisms.
Conclusion
Our results suggest considering both systematic screening of VTE and early therapeutic anticoagulation in severe ICU COVID‐19 patients.
Patients in the ICU were assigned to catheter insertion in the subclavian, jugular, or femoral vein. Subclavian catheterization had a lower risk of bloodstream infection and deep-vein thrombosis, and ...a higher risk of pneumothorax, than catheterization in the other two sites.
Subclavian, jugular, and femoral central venous catheterization are associated with infectious, thrombotic, and mechanical complications.
1
Catheter-related bloodstream infection has a significant effect on morbidity, mortality, and health care costs.
2
–
4
The risk of short-term catheter-related bloodstream infection is influenced mainly by extraluminal microbial colonization of the insertion site,
5
and such colonization is also associated with thrombosis.
6
,
7
Although the importance of catheter-related deep-vein thrombosis has been debated,
1
all thromboses have the potential to embolize. In addition, catheter-related deep-vein thrombosis
7
–
9
and pulmonary embolism
10
may remain undiagnosed in critically ill patients undergoing mechanical ventilation.
11
We conducted the 3SITES multicenter study to . . .
Purpose
To compare the efficacy of an antibiotic protocol guided by serum procalcitonin (PCT) with that of standard antibiotic therapy in severe acute exacerbations of COPD (AECOPDs) admitted to the ...intensive care unit (ICU).
Methods
We conducted a multicenter, randomized trial in France. Patients experiencing severe AECOPDs were assigned to groups whose antibiotic therapy was guided by (1) a 5-day PCT algorithm with predefined cutoff values for the initiation or stoppage of antibiotics (PCT group) or (2) standard guidelines (control group). The primary endpoint was 3-month mortality. The predefined noninferiority margin was 12%.
Results
A total of 302 patients were randomized into the PCT (
n
= 151) and control (
n
= 151) groups. Thirty patients (20%) in the PCT group and 21 patients (14%) in the control group died within 3 months of admission (adjusted difference, 6.6%; 90% CI − 0.3 to 13.5%). Among patients without antibiotic therapy at baseline (
n
= 119), the use of PCT significantly increased 3-month mortality 19/61 (31%) vs. 7/58 (12%),
p
= 0.015. The in-ICU and in-hospital antibiotic exposure durations, were similar between the PCT and control group (5.2 ± 6.5 days in the PCT group vs. 5.4 ± 4.4 days in the control group,
p
= 0.85 and 7.9 ± 8 days in the PCT group vs. 7.7 ± 5.7 days in the control group,
p
= 0.75, respectively).
Conclusion
The PCT group failed to demonstrate non-inferiority with respect to 3-month mortality and failed to reduce in-ICU and in-hospital antibiotic exposure in AECOPDs admitted to the ICU.
Severe ADAMTS13 deficiency occurs in 13% to 75% of thrombotic microangiopathies (TMA). In this context, the early identification of a severe, antibody-mediated, ADAMTS13 deficiency may allow to start ...targeted therapies such as B-lymphocytes-depleting monoclonal antibodies. To date, assays exploring ADAMTS13 activity require skill and are limited to only some specialized reference laboratories, given the very low incidence of the disease. To identify clinical features which may allow to predict rapidly an acquired ADAMTS13 deficiency, we performed a cross-sectional analysis of our national registry from 2000 to 2007. The clinical presentation of 160 patients with TMA and acquired ADAMTS13 deficiency was compared with that of 54 patients with detectable ADAMTS13 activity. ADAMTS13 deficiency was associated with more relapses during treatment and with a good renal prognosis. Patients with acquired ADAMTS13 deficiency had platelet count < 30 x 10(9)/L (adjusted odds ratio OR 9.1, 95% confidence interval CI 3.4-24.2, P<.001), serum creatinine level < or =200 micromol/L (OR 23.4, 95% CI 8.8-62.5, P<.001), and detectable antinuclear antibodies (OR 2.8, 95% CI 1.0-8.0, P<.05). When at least 1 criteria was met, patients with a severe acquired ADAMTS13 deficiency were identified with positive predictive value of 85%, negative predictive value of 93.3%, sensitivity of 98.8%, and specificity of 48.1%. Our criteria should be useful to identify rapidly newly diagnosed patients with an acquired ADAMTS13 deficiency to better tailor treatment for different pathophysiological groups.
Background
To assess the ability of procalcitonin (PCT) to distinguish between bacterial and nonbacterial causes of patients with severe acute exacerbation of COPD (AECOPD) admitted to the ICU, we ...conducted a retrospective analysis of two prospective studies including 375 patients with severe AECOPD with suspected lower respiratory tract infections. PCT levels were sequentially assessed at the time of inclusion, 6 h after and at day 1, using a sensitive immunoassay. The patients were classified according to the presence of a documented bacterial infection (including bacterial and viral coinfection) (BAC + group), or the absence of a documented bacterial infection (i.e., a documented viral infection alone or absence of a documented pathogen) (BAC- group). The accuracy of PCT levels in predicting bacterial infection (BAC + group) vs no bacterial infection (BAC- group) at different time points was evaluated by receiver operating characteristic (ROC) analysis.
Results
Regarding the entire cohort (
n
= 375), at any time, the PCT levels significantly differed between groups (Kruskal–Wallis test,
p
< 0.001). A pairwise comparison showed that PCT levels were significantly higher in patients with bacterial infection (
n
= 94) than in patients without documented pathogens (
n =
218) (
p
< 0.001). No significant difference was observed between patients with bacterial and viral infection (
n
= 63). For example, the median PCT-H
0
levels were 0.64 ng/ml 0.22–0.87 in the bacterial group vs 0.24 ng/ml 0.15–0.37 in the viral group and 0.16 ng/mL 0.11–0.22 in the group without documented pathogens. With a c-index of 0.64 (95% CI; 0.58–0.71) at H
0
, 0.64 95% CI 0.57–0.70 at H
6
and 0.63 (95% CI; 0.56–0.69) at H
24
, PCT had a low accuracy for predicting bacterial infection (BAC + group).
Conclusion
Despite higher PCT levels in severe AECOPD caused by bacterial infection, PCT had a poor accuracy to distinguish between bacterial and nonbacterial infection. Procalcitonin might not be sufficient as a standalone marker for initiating antibiotic treatment in this setting.
OBJECTIVE:Pressure-support ventilation is widely used during the weaning phase in patients with acute respiratory distress syndrome. The pressure-support level is adjusted to prevent ...ventilator-induced lung injury while limiting the patientʼs work of breathing. Neurally adjusted ventilatory assist is an assist mode that applies a positive pressure proportional to the integral of the electrical activity of the diaphragm. The objective was to assess the physiologic response to varying pressure-support ventilation and neurally adjusted ventilatory assist levels in selected acute respiratory distress syndrome patients and to evaluate the effect of neural triggering.
METHODS:We prospectively assessed 11 consecutive patients with acute respiratory distress syndrome attributable to pulmonary diseases. Pressure-support ventilation and neurally adjusted ventilatory assist were used in random order. Neurally adjusted ventilatory assist was used with a low electrical activity of the diaphragm trigger (neurally adjusted ventilatory assist–electrical activity of the diaphragm) and with a high electrical activity of the diaphragm trigger that led to rescue triggering by inspiratory flow (neurally adjusted ventilatory assist–inspiratory flow). With each ventilation modality, four levels of assistance (100%, 120%, 140%, and 160%) were used in random order. Statistical analysis was performed using analysis of variance for repeated measurements and mixed models.
MAIN RESULTS:Contrary to pressure-support ventilation, neurally adjusted ventilatory assist–electrical activity of the diaphragm and neurally adjusted ventilatory assist–inspiratory flow were associated with stable tidal volume levels despite increasing assistance. For the asynchrony index, an interaction was present between ventilation mode and assist level (p = .0076) because asynchrony index increased significantly with the pressure-support ventilation level (p = .004), but not with the neurally adjusted ventilatory assist–electrical activity of the diaphragm or neurally adjusted ventilatory assist–inspiratory flow level. The lowest asynchrony index was obtained with neurally adjusted ventilatory assist–electrical activity of the diaphragm.
CONCLUSION:Compared to pressure-support ventilation, neurally adjusted ventilatory assist in acute respiratory distress syndrome patients holds promise for limiting the risk of overassistance, preventing patient–ventilator asynchrony, and improving overall patient–ventilator interactions. Neural triggering (neurally adjusted ventilatory assist–electrical activity of the diaphragm) considerably decreased patient–ventilator asynchrony. (Crit Care Med 2010; 38:1830–1837)
Background. We investigated the possible association between fluoroquinolone use and the rate of methicillin-resistant Staphylococcus aureus (MRSA) recovery from consecutive hospitalized patients. ...Methods. We conducted a nonrandomized, prospective, controlled interventional “fluoroquinolone-free” study at 4 large teaching hospitals in northwest France, catering to a total of 5,882,600 persons. During the intervention period (January through December 2001), fluoroquinolone use was prohibited at 1 of the 4 hospitals (Caen Hospital), unless no effective alternative was available. Three university hospitals were used as controls because they had similar preintervention rates of MRSA. Results. During the intervention period (2001), the annual rate of fluoroquinolone use decreased from 54 to 5 defined daily doses per 1000 patients per day at Caen Hospital and remained stable in the control hospitals. At the end of the intervention, the rate of MRSA isolation was significantly lower at Caen Hospital than at the control hospitals (353 32.3% of 1093 S. aureus isolates were MRSA, compared with 2495 36.8% of 6787 isolates; odds ratio, 0.82; 95% confidence interval, 0.69–0.99; P = .036), as determined on the basis of a marginal model that took into account within-hospital clustering. In a before-after time series analysis, compared with forecasted rates, there was a significant downward trend in observed monthly rates of MRSA isolation at Caen Hospital at the end of the intervention. Conclusion. This quasi experimental study confirms the association between fluoroquinolone use and MRSA isolation among hospitalized patients.
The prediction of neurological outcome in comatose patients after cardiac arrest has major ethical and socioeconomic implications. The purpose of this study was to assess the capability of serum ...neuron-specific enolase (NSE), a biomarker of hypoxic brain damage, to predict death or vegetative state in comatose cardiac-arrest survivors.
We conducted a prospective observational cohort study in one university hospital and one general hospital Intensive Care Unit (ICU). All consecutive patients who suffered cardiac arrest and were subsequently admitted from June 2007 to February 2009 were considered for inclusion in the study. Patients who died or awoke within the first 48 hours of admission were excluded from the analysis. Patients were followed for 3 months or until death after cardiopulmonary resuscitation. The Cerebral Performance Categories scale (CPC) was used as the outcome measure; a CPC of 4-5 was regarded as a poor outcome, and a CPC of 1-3 a good outcome. Measurement of serum NSE was performed at 24 h and at 72 h after the time of cardiac arrest using an enzyme immunoassay. Clinicians were blinded to NSE results.
Ninety-seven patients were included. All patients were actively supported during the first days following cardiac arrest. Sixty-five patients (67%) underwent cooling after resuscitation. At 3 months 72 (74%) patients had a poor outcome (CPC 4-5) and 25 (26%) a good outcome (CPC 1-3). The median and Interquartile Range IQR levels of NSE at 24 h and at 72 h were significantly higher in patients with poor outcomes: NSE at 24 h: 59.4 ng/mL 37-106 versus 28.8 ng/mL 18-41 (p < 0.0001); and NSE at 72 h: 129.5 ng/mL 40-247 versus 15.7 ng/mL 12-19 (p < 0.0001). The Receiver Operator Characteristics (ROC) curve for poor outcome for the highest observed NSE value for each patient determined a cut-off value for NSE of 97 ng/mL to predict a poor neurological outcome with a specificity of 100% 95% CI = 87-100 and a sensitivity of 49% 95% CI = 37-60. However, an approach based on a combination of SSEPs, NSE and clinical-EEG tests allowed to increase the number of patients (63/72 (88%)) identified as having a poor outcome and for whom intensive treatment could be regarded as futile.
NSE levels measured early in the course of patient care for those who remained comatose after cardiac arrest were significantly higher in patients with outcomes of death or vegetative state. In addition, we provide a cut-off value for NSE (> 97 ng/mL) with 100% positive predictive value of poor outcome. Nevertheless, for decisions concerning the continuation of treatment in this setting, we emphasize that an approach based on a combination of SSEPs, NSE and clinical EEG would be more accurate for identifying patients with a poor neurological outcome.
OBJECTIVES:To investigate breathing-swallowing interactions in patients with chronic obstructive pulmonary disease requiring noninvasive mechanical ventilation and, if needed, to develop a technical ...modification of the ventilator designed to eliminate ventilator insufflations during swallowing.
DESIGN:We conducted a prospective, open-label, interventional study.
PATIENTS:Fifteen consecutive chronic obstructive pulmonary disease patients with exacerbations requiring ICU admission and NIV.
INTERVENTIONS:Swallowing performance and breathing-swallowing interactions were investigated noninvasively by chin electromyography, cervical piezoelectric sensor, and inductive respiratory plethysmography. Two water-bolus sizes (5 and 10 mL) were tested in random order. Swallowing was tested with and without noninvasive mechanical ventilation, in random order. First, a standard mechanical ventilator capable of delivering noninvasive mechanical ventilation was used. Second, a marketed device was equipped with an off-switch for use during swallowing.
MEASUREMENTS AND MAIN RESULTS:Swallowing performance and breathing-swallowing interactions were investigated noninvasively by chin electromyography, cervical piezoelectric sensor, and inductive respiratory plethysmography. Two water bolus sizes (5 and 10 mL) were tested in random order. Swallowing was tested with and without noninvasive mechanical ventilation in random order. First, a standard mechanical ventilator capable of delivering noninvasive mechanical ventilation was used. Swallowing efficiency, breathing-swallowing synchronization, and Borg Scale dyspnea scores improved significantly with noninvasive mechanical ventilation. However, swallowing induced ventilator triggering followed by autotriggering. To improve patient-ventilator synchrony, a marketed device was equipped with an off-switch for use during swallowing. This device completely eliminated swallowing-induced ventilator triggering and postswallow autotriggering.
CONCLUSION:Patients with chronic obstructive pulmonary disease admitted to the ICU for acute exacerbations had abnormal breathing-swallowing interactions and dyspnea, which improved with noninvasive mechanical ventilation. Furthermore, a ventilator device with a simple switch-off pushbutton to eliminate insufflations during swallows prevented swallowing-induced ventilator triggering and postswallow autotriggering.
IntroductionPrognosis of patients with COVID-19 depends on the severity of the pulmonary affection. The most severe cases may progress to acute respiratory distress syndrome (ARDS), which is ...associated with a risk of long-term repercussions on respiratory function and neuromuscular outcomes. The functional repercussions of severe forms of COVID-19 may have a major impact on quality of life, and impair the ability to return to work or exercise. Social inequalities in healthcare may influence prognosis, with socially vulnerable individuals more likely to develop severe forms of disease. We describe here the protocol for a prospective, multicentre study that aims to investigate the influence of social vulnerability on functional recovery in patients who were hospitalised in intensive care for ARDS caused by COVID-19. This study will also include an embedded qualitative study that aims to describe facilitators and barriers to compliance with rehabilitation, describe patients’ health practices and identify social representations of health, disease and care.Methods and analysisThe "Functional Recovery From Acute Respiratory Distress Syndrome (ARDS) Due to COVID-19: Influence of Socio-Economic Status" (RECOVIDS) study is a mixed-methods, observational, multicentre cohort study performed during the routine follow-up of post-intensive care unit (ICU) functional recovery after ARDS. All patients admitted to a participating ICU for PCR-proven SARS-CoV-2 infection and who underwent chest CT scan at the initial phase AND who received respiratory support (mechanical or not) or high-flow nasal oxygen, AND had ARDS diagnosed by the Berlin criteria will be eligible. The primary outcome is the presence of lung sequelae at 6 months after ICU discharge, defined either by alterations on pulmonary function tests, oxygen desaturation during a standardised 6 min walk test or fibrosis-like pulmonary findings on chest CT. Patients will be considered to be socially disadvantaged if they have an "Evaluation de la Précarité et des Inégalités de santé dans les Centres d’Examen de Santé" (EPICES) score ≥30.17 at inclusion.Ethics and disseminationThe study protocol and the informed consent form were approved by an independent ethics committee (Comité de Protection des Personnes Sud Méditerranée II) on 10 July 2020 (2020-A02014-35). All patients will provide informed consent before participation. Findings will be published in peer-reviewed journals and presented at national and international congresses.Trial registration numberNCT04556513
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