Purpose
Septic shock is one of the leading causes of acute kidney injury. The mechanisms of this injury remain mostly unknown notably because of the lack of data on renal histological lesions in ...humans.
Methods
Kidney biopsy was performed immediately post-mortem in consecutive patients who died of septic shock. Comparisons were made with specimens from eight patients who died of trauma on scene and nine ICU patients that died of non-septic causes.
Results
Nineteen septic patients were included, 11 were male, and age was 72 ± 12 years. Anuria occurred in all patients 2.2 ± 1.4 days before death. Seven patients had disseminated intravascular coagulation. In all patients we observed (1) acute tubular lesions whose intensity correlated with blood lactate concentration; (2) intense infiltration by leukocytes, mainly monocytic, in glomeruli and interstitial capillaries as compared to controls; (3) presence of tubular cell apoptosis proved by the presence of apoptotic bodies (2.9% of tubular cells) significantly more frequently than in controls and confirmed by TUNEL and activated caspase-3 staining. Arteriolar/arterial thromboses were observed in only 4 of 19 patients, without any association with presence of disseminated intravascular coagulation.
Conclusions
Kidney lesions in septic shock go beyond those associated with simple acute tubular injury, notably capillary leukocytic infiltration and apoptosis. Vascular thrombosis, however, did not appear to play a major role in the majority of patients. The extent to which these lesions are specific to sepsis or are common to all multi-organ failure independent of its cause is yet to be elucidated.
The occurrence of mediastinitis after cardiac surgery remains a rare and severe complication associated with poor outcomes. Whereas bacterial mediastinitis have been largely described, little is ...known about their fungal etiologies. We report incidence, characteristics and outcome of post-cardiac surgery fungal mediastinitis.
Multicenter retrospective study among 10 intensive care units (ICU) in France and Belgium of proven cases of fungal mediastinitis after cardiac surgery (2009-2019).
Among 73,688 cardiac surgery procedures, 40 patients developed fungal mediastinitis. Five were supported with left ventricular assist device and five with veno-arterial extracorporeal membrane oxygenation before initial surgery. Twelve patients received prior heart transplantation. Interval between initial surgery and mediastinitis was 38 17-61 days. Only half of the patients showed local signs of infection. Septic shock was uncommon at diagnosis (12.5%). Forty-three fungal strains were identified: Candida spp. (34 patients), Trichosporon spp. (5 patients) and Aspergillus spp. (4 patients). Hospital mortality was 58%. Survivors were younger (59 43-65 vs. 65 61-73 yo; p = 0.013), had lower body mass index (24 20-26 vs. 30 24-32 kg/m
; p = 0.028) and lower Simplified Acute Physiology Score II score at ICU admission (37 28-40 vs. 54 34-61; p = 0.012).
Fungal mediastinitis is a very rare complication after cardiac surgery, associated with a high mortality rate. This entity should be suspected in patients with a smoldering infectious postoperative course, especially those supported with short- or long-term invasive cardiac support devices, or following heart transplantation.
There is insufficient research into the use of mechanical ventilation with increased inspiratory oxygen concentration (FiO
) and fluid resuscitation with hypertonic saline solution in patients with ...septic shock. We tested whether these interventions are associated with reduced mortality.
This two-by-two factorial, multicentre, randomised, clinical trial (HYPERS2S) recruited patients aged 18 years and older with septic shock who were on mechanical ventilation from 22 centres in France. Patients were randomly assigned 1:1:1:1 to four groups by a computer generated randomisation list stratified by site and presence or absence of acute respiratory distress syndrome by use of permuted blocks of random sizes. Patients received, in an open-labelled manner, mechanical ventilation either with FiO
at 1·0 (hyperoxia) or FiO
set to target an arterial haemoglobin oxygen saturation of 88-95% (normoxia) during the first 24 h; patients also received, in a double-blind manner, either 280 mL boluses of 3·0% (hypertonic) saline or 0·9% (isotonic) saline for fluid resuscitation during the first 72 h. The primary endpoint was mortality at day 28 after randomisation in the intention-to-treat population. This study was registered with ClinicalTrials.gov, number NCT01722422.
Between Nov 3, 2012, and June 13, 2014, 442 patients were recruited and assigned to a treatment group (normoxia n=223 or hyperoxia n=219; isotonic n=224 or hypertonic n=218). The trial was stopped prematurely for safety reasons. 28 day mortality was recorded for 434 patients; 93 (43%) of 217 patients had died in the hyperoxia group versus 77 (35%) of 217 patients in the normoxia group (hazard ratio HR 1·27, 95% CI 0·94-1·72; p=0·12). 89 (42%) of 214 patients had died in the hypertonic group versus 81 (37%) of 220 patients in the isotonic group (HR 1·19, 0·88-1·61; p=0·25). We found a significant difference in the overall incidence of serious adverse events between the hyperoxia (185 85%) and normoxia groups (165 76%; p=0·02), with a clinically relevant doubling in the hyperoxia group of the number of patients with intensive care unit-acquired weakness (24 11% vs 13 6%; p=0·06) and atelectasis (26 12% vs 13 6%; p=0·04) compared with the normoxia group. We found no statistical difference for serious adverse events between the two saline groups (p=0·23).
In patients with septic shock, setting FiO
to 1·0 to induce arterial hyperoxia might increase the risk of mortality. Hypertonic (3%) saline did not improve survival.
The French Ministry of Health.
Background: Severe diaphragmatic dysfunction can prolong mechanical ventilation after cardiac surgery. An ultrasonographic criterion
for diagnosing severe diaphragmatic dysfunction defined by a ...reference technique such as transdiaphragmatic pressure measurements
has never been determined.
Methods: Twenty-eight patients requiring mechanical ventilation > 7 days postoperatively were studied. Esophageal and gastric pressures
were measured to calculate transdiaphragmatic pressure during maximal inspiratory effort and the Gilbert index, which evaluates
the diaphragm contribution to respiratory pressure swings during quiet ventilation. Ultrasonography allowed measuring right
and left hemidiaphragmatic excursions during maximal inspiratory effort. Best E is the greatest positive value from either
hemidiaphragm. Twenty cardiac surgery patients with uncomplicated postoperative course were also evaluated with ultrasonography
preoperatively and postoperatively. Measurements were performed in semirecumbent position.
Results: Transdiaphragmatic pressure during maximal inspiratory effort was below normal value in 27 of the 28 patients receiving prolonged
mechanical ventilation (median, 39 cm H 2 O; interquartile range IQR 28 cm H 2 O). Eight patients had Gilbert indexes ⤠0 indicating severe diaphragmatic dysfunction. Best E was lower in patients with
Gilbert index ⤠0 than > 0 (30 mm; IQR, 10 mm; vs 19 mm; IQR, 7 mm, respectively; p = 0.001). Best E < 25 mm had a positive
likelihood ratio of 6.7 (95% confidence interval CI, 2.4 to 19) and a negative likelihood ratio of 0 (95% CI, 0 to 1.1)
for having a Gilbert index ⤠0. None of the patients with uncomplicated course had Best E < 25 mm either preoperatively or
postoperatively.
Conclusions: Ultrasonographic-based determination of hemidiaphragm excursions in patients requiring prolonged mechanical ventilation after
cardiac surgery may help identify those with and without severe diaphragmatic dysfunction as defined by the Gilbert index.
Data collected from two cohorts of patients aged > or =80 yrs and admitted to an intensive care unit in France were compared to determine whether intensive care unit care and survival had evolved ...from the 1990s to the 2000s.
Retrospective cohort study on patient data attained during intensive care unit stays.
18-bed intensive care unit in an academic medical center.
Two cohorts of patients aged > or =80 yrs, admitted to an intensive care unit at a 10-yr interval.
None.
The first cohort comprised 348 patients admitted between January 1992 and December 1995, and the second cohort, 373 patients admitted between January 2001 and December 2004. There was no difference in age between the two cohorts, but patients in the second had significantly less history of functional limitation and significantly more acute illness (Simplified Acute Physiology Score II 43 +/- 18 vs. 57 +/- 25, respectively, p < .0001). Patients in the second cohort had a significantly higher Omega Score, had a higher occurrence of renal replacement therapy, and received vasopressors more frequently than the patients in the first cohort, even when adjusted for age, sex, Knaus classification, Simplified Acute Physiology Score II, and intensive care unit admission cause. Intensive care unit mortality was 65% and 64% for the first and second cohorts, respectively. In multivariate analysis (including age, Knaus classification, Simplified Acute Physiology Score II and first vs. second period) for association with intensive care unit survival, the 2001-2004 period was associated with a near tripling of chances of survival (odds ratio 2.9; 95% confidence interval, 1.92-4.47, p < .0001).
The characteristics and intensity of treatment for elderly people admitted to the intensive care unit changed significantly over a decade. The intensity of treatments has increased over time and survival has improved over time as well. A potential link between increased treatment and improved survival in the elderly may be evoked.
Purpose
To describe laryngeal injuries after intubation in an intensive care unit and assess their risk factors and their association with post-extubation stridor (PES) and extubation failure.
...Methods
Prospective study including 136 patients extubated after more than 24 h of mechanical ventilation. Fiberoptic endoscopic examination of the larynx was systemically performed within 6 h after extubation in order to record four types of laryngeal anomalies: edema, ulceration, granulation, and abnormal vocal cord (VC) mobility.
Results
Median duration of intubation was 3 days (min 24 h, max 56 days). Laryngeal injuries were frequent (73% of patients) and were associated with duration of intubation odds ratios (OR) 1.11, 95% confidence interval (CI) 1.02–1.21,
P
= 0.02 and absence of use of myorelaxant drugs at intubation (OR 0.13, 95% CI 0.01–0.99,
P
= 0.05). Eighteen patients presented a PES. Lesions associated with PES were edema (67%,
P
< 0.01) and abnormal VC mobility (67%,
P
< 0.01). These injuries were associated with duration of intubation (OR 1.05, 95% CI 1.01–1.09,
P
= 0.04), emergency intubation (OR 2.7, 95% CI 1.2–6.4,
P
= 0.02), and height/endotracheal tube size ratio (OR 0.97, 95% CI 0.95–0.99,
P
= 0.01). Seventeen patients were reintubated within 48 h following extubation. Laryngeal examination of these patients more frequently showed granulation (29.4%,
P
= 0.02) and abnormal VC mobility (58.8%,
P
< 0.01).
Conclusion
This study found a high frequency of laryngeal injuries after extubation in ICU, which were associated with intubation duration and patient’s height/ETT size ratio. Edema was not the only injury responsible for PES, and although edema is frequent it is not the only injury associated with reintubation.
Tuberculous meningitis (TBM) is a devastating infection in tuberculosis endemic areas with limited access to intensive care. Functional outcomes of severe adult TBM patients admitted to the ICU in ...nonendemic areas are not known.
We conducted a retrospective multicenter cohort study (2004-2016) of consecutive TBM patients admitted to 12 ICUs in the Paris area, France. Clinical, biological, and brain magnetic resonance imaging (MRI) findings at admission associated with a poor functional outcome (i.e., a score of 3-6 on the modified Rankin scale (mRS) at 90 days) were identified by logistic regression. Factors associated with 1-year mortality were investigated by Cox proportional hazards modeling.
We studied 90 patients, of whom 61 (68%) had a score on the Glasgow Coma Scale ≤ 10 at presentation and 63 (70%) required invasive mechanical ventilation. Brain MRI revealed infarction and hydrocephalus in 38/75 (51%) and 25/75 (33%) cases, respectively. A poor functional outcome was observed in 55 (61%) patients and was independently associated with older age (adjusted odds ratio (aOR) 1.03, 95% CI 1.0-1.07), cerebrospinal fluid protein level ≥ 2 g/L (aOR 5.31, 95% CI 1.67-16.85), and hydrocephalus on brain MRI (aOR 17.2, 95% CI 2.57-115.14). By contrast, adjunctive steroids were protective (aOR 0.13, 95% CI 0.03-0.56). The multivariable adjusted hazard ratio of adjunctive steroids for 1-year mortality (47%, 95% CI 37%-59%) was 0.23 (95% CI 0.11-0.44). Among survivors at 1 year, functional independence (mRS of 0-2) was observed in 27/37 (73%, 95% CI 59%-87%) cases.
A poor functional outcome in adult TBM patients admitted to the ICU in a nonendemic area is observed in 60% of cases and is independently associated with elevated cerebrospinal fluid protein level and hydrocephalus. Our data also suggest a protective effect of adjunctive steroids, with reduced disability and mortality, irrespective of immune status and severity of disease at presentation. One-year follow-up revealed functional independence in most survivors.
Rationale, aims, and objectives
There is at present no standard methodology to analyse the organizational impacts (OIs) of medical devices (MDs), and the field is still in its infancy. The aim of the ...present study was to assess, at a hospital level, the organizational and economic impacts of the introduction of a new MD, specifically the single‐use flexible bronchoscope (FB).
Methods
Both the organizational and economic impacts of the single‐use FB were evaluated in comparison with the reusable FB currently used as standard practice in our institution. First, process maps were created for both devices (reusable and single use). Based on the 12 types of OI defined by Roussel et al, interviews were conducted with all stakeholders, and the positive and negative aspects of the reusable and single‐use processes were analysed. In a second step, microcosting analysis was conducted to determine the most economical balance in use of the 2 technologies.
Results
Process maps highlighted the complexity of the reusable device process when compared with the single‐use device process. Among the 12 types of OI, the single‐use FB process scored better than the reusable FB process in 75% of cases. With the “fleet” of 15 reusable FBs available in our institution, using single‐use FBs would represent an extra cost of €154 per procedure. Single‐use and reusable devices would have the same cost (€232 per procedure) with a theoretical annual activity of 328 bronchoscopies, which is much lower than our current activity (1644 procedures per year).
Conclusions
Organizational impact should be considered when assessing MDs. We show in this study that from an organizational viewpoint, there are many advantages to using single‐use bronchoscopes. However, in economic impact, it is more cost‐effective for our institution, with more than 1500 bronchoscopies performed annually, to use reusable devices.
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