Study objective We study the performance of capnometry in the detection of early complications after deliberate drug poisoning. Methods This was a prospective cohort study of self-poisoned adult ...patients who presented at an emergency department (ED) between April 20, 2012, and May 6, 2014. Patients who ingested at least 1 neurologic or respiratory depressant drug were included. The primary outcome was the predictive value of an end tidal CO2 ( etco2 ) measurement greater than or equal to 50 mm Hg for the detection of early complications defined a priori by hypoxia requiring oxygen greater than or equal to 3 L/min, bradypnea less than or equal to 10 breaths/min, or ICU admission after intubation or antidote administration because of unresponsiveness to pain or respiratory arrest. Consciousness scales and clinical data were recorded at admission and every 30 minutes. Noninvasive etco2 was continuously measured for 2 hours after inclusion unless the patient was admitted to the ICU. Patients and physicians were blinded to etco2 values. Results Two hundred one patients were included, 35 of whom exhibited at least 1 complication. An etco2 measurement greater than or equal to 50 mm Hg predicted the onset of a complication, with a sensitivity of 46% (95% confidence interval CI 29% to 63%) and a specificity of 80% (95% CI 73% to 86%), leading to a positive predictive value of 33% (95% CI 20% to 48%) and a negative predictive value of 88% (95% CI 81% to 92%). etco2 was less able to predict complications than the Glasgow Coma Scale score at inclusion. Conclusion Capnometry in isolation does not provide adequate prediction of early complications in self-poisoned patients referred to the ED. A dynamic minute-by-minute assessment of etco2 could be more predictive.
Summary Background Reduced duration of antibiotic treatment might contain the emergence of multidrug-resistant bacteria in intensive care units. We aimed to establish the effectiveness of an ...algorithm based on the biomarker procalcitonin to reduce antibiotic exposure in this setting. Methods In this multicentre, prospective, parallel-group, open-label trial, we used an independent, computer-generated randomisation sequence to randomly assign patients in a 1:1 ratio to procalcitonin (n=311 patients) or control (n=319) groups; investigators were masked to assignment before, but not after, randomisation. For the procalcitonin group, antibiotics were started or stopped based on predefined cut-off ranges of procalcitonin concentrations; the control group received antibiotics according to present guidelines. Drug selection and the final decision to start or stop antibiotics were at the discretion of the physician. Patients were expected to stay in the intensive care unit for more than 3 days, had suspected bacterial infections, and were aged 18 years or older. Primary endpoints were mortality at days 28 and 60 (non-inferiority analysis), and number of days without antibiotics by day 28 (superiority analysis). Analyses were by intention to treat. The margin of non-inferiority was 10%. This trial is registered with ClinicalTrials.gov , number NCT00472667. Findings Nine patients were excluded from the study; 307 patients in the procalcitonin group and 314 in the control group were included in analyses. Mortality of patients in the procalcitonin group seemed to be non-inferior to those in the control group at day 28 (21·2% 65/307 vs 20·4% 64/314; absolute difference 0·8%, 90% CI −4·6 to 6·2) and day 60 (30·0% 92/307 vs 26·1% 82/314; 3·8%, −2·1 to 9·7). Patients in the procalcitonin group had significantly more days without antibiotics than did those in the control group (14·3 days SD 9·1 vs 11·6 days SD 8·2; absolute difference 2·7 days, 95% CI 1·4 to 4·1, p<0·0001). Interpretation A procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical patients in intensive care units could reduce antibiotic exposure and selective pressure with no apparent adverse outcomes. Funding Assistance Publique-Hôpitaux de Paris, France, and Brahms, Germany.
Abstract Objective Early unplanned readmission to the intensive care unit (ICU) carries a poor prognosis, and post-ICU mortality may be related, in part, to premature ICU discharge. Our objectives ...were to identify independent risk factors for early post-ICU readmission or death and to construct a prediction model. Design Retrospective analysis of a prospective database was done. Setting Four ICUs of the French Outcomerea network participated. Patients Patients were consecutive adults with ICU stay longer than 24 hours who were discharged alive to same-hospital wards without treatment-limitation decisions. Main results Of 5014 admitted patients, 3462 met our inclusion criteria. Age was 60.6 ± 17.6 years, and admission Simplified Acute Physiology Score II (SAPS II) was 35.1 ± 15.1. The rate of death or ICU readmission within 7 days after ICU discharge was 3.0%. Independent risk factors for this outcome were age, SAPS II at ICU admission, use of a central venous catheter in the ICU, Sepsis-related Organ Failure Assessment and Systemic Inflammatory Response Syndrome scores before ICU discharge, and discharge at night. The predictive model based on these variables showed good calibration. Compared with SAPS II at admission or Stability and Workload Index for Transfer at discharge, discrimination was better with our model (area under receiver operating characteristics curve, 0.74; 95% confidence interval, 0.68-0.79). Conclusion Among patients without treatment-limitation decisions and discharged alive from the ICU, 3.0% died or were readmitted within 7 days. Independent risk factors were indicators of patients' severity and discharge at night. Our prediction model should be evaluated in other ICU populations.
Objectives Within the past decade, biochemical markers have emerged as attractive tools to assess pulmonary arterial hypertension (PAH) prognosis, being noninvasive and easily repeatable. The ...objective of this study was to determine whether biomarkers measured at initial diagnostic right-sided heart catheterization predict 3-year all-cause mortality for incident cases of PAH independently of clinical and hemodynamic parameters. Methods Patients with incident PAH were enrolled between December 2003 and April 2006 in six centers from the French Network on Pulmonary Hypertension and followed for 3 years. Venous blood samples were taken during right-sided heart catheterization, and analyses were centralized. Results Among 110 enrolled patients, 11 underwent lung or heart/lung transplantation, and 27 died during follow-up. The Kaplan-Meier estimates of survival were 91%, 78%, and 75% at 1, 2, and 3 years, respectively. Plasma big endothelin-1 (hazard ratio HR per 1-SD increase, 1.48; 95% CI, 1.14-1.92), serum troponin T > 0.01 mg/L (HR, 2.35; 95% CI, 1.05-5.29), and urinary F2 -isoprostanes (15-F2t -isoprostane) (HR per 1-SD increase, 1.76; 95% CI, 1.31-2.36) were associated with increased unadjusted hazard of death. In multivariate analysis adjusting for patient characteristics, the level of urinary F2 -isoprostanes was the only biomarker that remained independently associated with increased hazard of death (HR per 1-SD increase, 1.82; 95% CI, 1.28-2.60). Conclusions This study shows that levels of urinary F2 -isoprostane, a biomarker of lipid peroxidation, quantified at initial diagnostic right-sided heart catheterization are independently associated with mortality in a cohort of patients with incident PAH.
Sepsis Severe or Septic Shock Tolsma, Violaine, MD; Schwebel, Carole, MD, PhD; Azoulay, Elie, MD, PhD ...
Chest,
November 2014, Volume:
146, Issue:
5
Journal Article
Peer reviewed
OBJECTIVES: This study evaluated the influence of the immune profile on the outcome at day 28 (D28) of patients admitted to the ICU for septic shock or severe sepsis. METHODS We conducted an ...observational study using a prospective multicenter database and included all patients admitted to 11 ICUs for severe sepsis or septic shock from January 1997 to August 2011. Seven profiles of immunodeficiency were defined. The prognostic analysis used a competitive risk model (Fine and Gray), in which being alive at ICU or hospital discharge before D28 competed with death. RESULTS Among the 1,981 included patients, 607 (31%) were immunocompromised (including nonneutropenic solid tumor 19.6%, nonneutropenic hematologic malignancies 26.3%, and all-cause neutropenia 28%). Compared with immunocompetent patients, immunocompromised patients were younger, with less comorbidity, were more often admitted for medical reasons, and presented less often with septic shock. The D28 crude mortality was 31.3% in immunocompromised patients and 28.8% in immunocompetent patients ( P = .26). However, after adjustment for other prognostic factors, immunodeficiency was an independent risk factor for death at D28 (subdistribution hazard ratio sHR, 1.37; 95% CI, 1.12-1.67). The immunodeficiency profiles independently associated with death were AIDS (sHR = 1.9), non-neutropenic solid tumor (sHR = 1.8), nonneutropenic hematologic malignancies (sHR = 1.4), and all-cause neutropenia (sHR = 1.7). CONCLUSIONS Immunodeficiency is common in patients with severe sepsis or septic shock. Despite a similar crude mortality, immunodeficiency was associated with an increased risk of short-term mortality after multivariate analysis. Neutropenia and specific, but not all, profiles of immunodeficiency were independently associated with an increased risk of death.
About 5% of patients with coronavirus disease-2019 are admitted to the ICU for acute hypoxemic respiratory failure. Opinions differ on whether invasive mechanical ventilation should be used as ...first-line therapy over noninvasive oxygen support. The aim of the study was to assess the effect of early invasive mechanical ventilation in coronavirus disease-2019 with acute hypoxemic respiratory failure on day-60 mortality.
Multicenter prospective French observational study.
Eleven ICUs of the French OutcomeRea network.
Coronavirus disease-2019 patients with acute hypoxemic respiratory failure (Pao
/Fio
≤ 300 mm Hg), without shock or neurologic failure on ICU admission, and not referred from another ICU or intermediate care unit were included.
We compared day-60 mortality in patients who were on invasive mechanical ventilation within the first 2 calendar days of the ICU stay (early invasive mechanical ventilation group) and those who were not (nonearly invasive mechanical ventilation group). We used a Cox proportional-hazard model weighted by inverse probability of early invasive mechanical ventilation to determine the risk of death at day 60.
The 245 patients included had a median (interquartile range) age of 61 years (52-69 yr), a Simplified Acute Physiology Score II score of 34 mm Hg (26-44 mm Hg), and a Pao
/Fio
of 121 mm Hg (90-174 mm Hg). The rates of ICU-acquired pneumonia, bacteremia, and the ICU length of stay were significantly higher in the early (
= 117 48%) than in the nonearly invasive mechanical ventilation group (
= 128 52%),
< 0.01. Day-60 mortality was 42.7% and 21.9% in the early and nonearly invasive mechanical ventilation groups, respectively. The weighted model showed that early invasive mechanical ventilation increased the risk for day-60 mortality (weighted hazard ratio =1.74; 95% CI, 1.07-2.83, p=0.03).
In ICU patients admitted with coronavirus disease-2019-induced acute hypoxemic respiratory failure, early invasive mechanical ventilation was associated with an increased risk of day-60 mortality. This result needs to be confirmed.
The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to ...evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions.
Multicenter prospective French observational study.
Fourteen ICUs of the French OutcomeRea network.
From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission.
None.
We identified 373 stroke patients (ischemic,
= 167 45%; hemorrhagic,
= 206 55%) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 95% CI, 2.78-4.65) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 95% CI, 2.97-5.11). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 3-9 vs 2 d 1-6 d;
< 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (
< 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 95% CI, 1.01-2.59) and a prestroke modified Rankin score greater than 2 (2.38 1.27-4.55). In hemorrhagic stroke, an age greater than 70 years (2.29 1.43-3.69) and a Glasgow Coma Scale score less than 8 (2.15 1.08-4.3) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 0.82-0.97).
In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.
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