The efficacy of venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS) remains controversial.
In an international clinical trial, we ...randomly assigned patients with very severe ARDS, as indicated by one of three criteria - a ratio of partial pressure of arterial oxygen (Pao
) to the fraction of inspired oxygen (Fio
) of less than 50 mm Hg for more than 3 hours; a Pao
:Fio
of less than 80 mm Hg for more than 6 hours; or an arterial blood pH of less than 7.25 with a partial pressure of arterial carbon dioxide of at least 60 mm Hg for more than 6 hours - to receive immediate venovenous ECMO (ECMO group) or continued conventional treatment (control group). Crossover to ECMO was possible for patients in the control group who had refractory hypoxemia. The primary end point was mortality at 60 days.
At 60 days, 44 of 124 patients (35%) in the ECMO group and 57 of 125 (46%) in the control group had died (relative risk, 0.76; 95% confidence interval CI, 0.55 to 1.04; P=0.09). Crossover to ECMO occurred a mean (±SD) of 6.5±9.7 days after randomization in 35 patients (28%) in the control group, with 20 of these patients (57%) dying. The frequency of complications did not differ significantly between groups, except that there were more bleeding events leading to transfusion in the ECMO group than in the control group (in 46% vs. 28% of patients; absolute risk difference, 18 percentage points; 95% CI, 6 to 30) as well as more cases of severe thrombocytopenia (in 27% vs. 16%; absolute risk difference, 11 percentage points; 95% CI, 0 to 21) and fewer cases of ischemic stroke (in no patients vs. 5%; absolute risk difference, -5 percentage points; 95% CI, -10 to -2).
Among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy. (Funded by the Direction de la Recherche Clinique et du Développement and the French Ministry of Health; EOLIA ClinicalTrials.gov number, NCT01470703 .).
Le séminaire de recherche translationnelle 2016 organisé par la Société de Réanimation de Langue Française s’est focalisé sur les mécanismes de réponse à l’agression et de réparation pulmonaire. Le ...poumon représente une interface essentielle entre l’hôte et son environnement et est à ce titre soumis à des agressions constantes et multiples. La réanimation s’est en grande partie construite autour de la prise en charge de la défaillance respiratoire. Au-delà du traitement étiologique et du support ventilatoire, se pose la problématique récurrente du développement de thérapeutiques adjuvantes à visée immunomodulatrice. Le développement de telles thérapeutiques innovantes est conditionné par les avancées dans la compréhension de la physiopathologie de l’agression pulmonaire aiguë, ainsi que par la validation au lit du patient d’outils d’évaluation permettant de quantifier l’effet des interventions thérapeutiques.
Summary
Background
Among patients with thrombotic microangiopathies, acute kidney injury (AKI) is the hallmark of hemolytic uremic syndrome (HUS) and is largely underestimated in patients with ...thrombotic thrombocytopenic purpura (TTP).
Objective
We sought to report AKI features and outcomes in patients with TTP.
Methods
We conducted a retrospective study of 92 patients with TTP assessed by low ADAMTS13 activity (< 10%) between 2001 and 2013. A logistic regression identified variables independently associated with AKI.
Results
Among the 92 patients, 54 (58.7%) presented with AKI, including 25 (46.3%) with stage 3 AKI. Fourteen (27.4%) patients had a nephrotic‐range proteinuria and 21 (45.6%) had hemoglobinuria. Hematuria and leucocyturia were detected in 19 (41.3%) and 16 patients (36.4%), respectively. Renal replacement therapy (RRT) was required in 14 patients (25.9%). Six months after TTP remission, RRT‐free patients had median (IQR) MDRD (Modification of Diet in Renal Disease formula estimating the glomerular filtration rate) of 93 mL min−1 per 1.73 m2 (68.8–110) and three patients required long‐term dialysis. Mild or moderate chronic renal disease occurred in 23/54 (42.6%) AKI patients. By multivariate analysis, serum level of complement component 3 at admission was the only factor independently associated with AKI (OR per 0.25 unit decrease of C3, 0.85; CI, 1.82–8.33; P = 0.001).
Conclusions
In patients with TTP, AKI is present in more than half the patients, and half of those will have lasting renal effects. Further studies to better understand the pathophysiology of renal involvement in patients with TTP and to identify a subset of patients with TTP syndrome overlapping HUS are warranted.
Cytomegalovirus (CMV) infection is associated with poor outcome in ICU patients. However, data on immunocompromised patients are scarce. This study aims to describe characteristics and outcomes of ...critically ill hematological patients and CMV infection. CMV disease characteristics and relationship between CMV viral load, CMV disease, coinfections by other pathogens and outcomes are described.
Retrospective single center study (Jan 2010-Dec 2017). Adult patients, admitted to the ICU, having underlying hematological malignancy and CMV infection were included. Results are reported as median (interquartile) or n (%). Factors associated with hospital mortality or CMV disease were analysed using logistic regression.
178 patients were included (median age 55y 42–64, 69.1% male). Hospital mortality was 53% (n = 95). Median viral load was 2.7 Log 2.3–3.5. CMV disease occurred in 44 (24.7%) patients. Coinfections concerned 159 patients (89.3%). After adjustment for confounders, need for vasopressors (OR 2.53; 95%CI 1.11–5.97) and viral load (OR 1.88 per Log; 95%CI 1.29–2.85) were associated with hospital mortality. However, neither CMV disease nor treatment were associated with outcomes. Allogeneic stem cell transplantation (OR 2.55; 95%CI 1.05–6.16), mechanical ventilation (OR 4.11; OR 1.77–10.54) and viral load (OR 1.77 per Log; 95%CI 1.23–2.61) were independently associated with CMV disease. Coinfections were not associated with CMV disease or hospital mortality.
In critically-ill hematological patients, CMV viral load is independently associated with hospital mortality. Conversely, neither CMV disease nor treatment was associated with outcome suggesting viral load to be a surrogate for immune status rather than a cause of poor outcome.
Background
Transient and persistent acute kidney injury (AKI) could share similar physiopathological mechanisms. The objective of our study was to assess prognostic impact of AKI duration on ICU ...mortality.
Design
Retrospective analysis of a prospective database via cause-specific model, with 28-day ICU mortality as primary end point, considering discharge alive as a competing event and taking into account time-dependent nature of renal recovery. Renal recovery was defined as a decrease of at least one KDIGO class compared to the previous day.
Setting
23 French ICUs.
Patients
Patients of a French multicentric observational cohort were included if they suffered from AKI at ICU admission between 1996 and 2015.
Intervention
None.
Results
A total of 5242 patients were included. Initial severity according to KDIGO creatinine definition was AKI stage 1 for 2458 patients (46.89%), AKI stage 2 for 1181 (22.53%) and AKI stage 3 for 1603 (30.58%). Crude 28-day ICU mortality according to AKI severity was 22.74% (
n
= 559), 27.69% (
n
= 327) and 26.26% (
n
= 421), respectively. Renal recovery was experienced by 3085 patients (58.85%), and its rate was significantly different between AKI severity stages (
P
< 0.01). Twenty-eight-day ICU mortality was independently lower in patients experiencing renal recovery CSHR 0.54 (95% CI 0.46–0.63),
P
< 0.01. Lastly, RRT requirement was strongly associated with persistent AKI whichever threshold was chosen between day 2 and 7 to delineate transient from persistent AKI.
Conclusions
Short-term renal recovery, according to several definitions, was independently associated with higher mortality and RRT requirement. Moreover, distinction between transient and persistent AKI is consequently a clinically relevant surrogate outcome variable for diagnostic testing in critically ill patients.
Blended-learning methods could be a response to student nonattendance. Non-compulsory teaching combining e-learning/interactive face-to-face sessions has been implemented at Paris-Diderot Medical ...School for the teaching of intensive care and emergency medicine during the 2018/2019 university period. The aim of the study was to assess this newly-implemented blended teaching.
Questionnaire submitted to the 388 DFASM3 medical students present at the faculty exam of intensive care/emergency medicine. Attendance at a teaching modality was defined by the follow-up of more than half of this teaching modality. Correlations between attendance at e-learning and/or interactive face-to-face sessions, and grade were performed.
A total of 358/388 (92%) students participated in this survey. A quarter of the students (88/321 - 25%) reported they usually attended at traditional lectures. Regarding blended-learning, 210/317 (67%) students reported having attended at e-learning courses and 84/321 (27%) attended at interactive face-to-face sessions. The distribution of students according to their attendance at e-learning and/or interactive face-to-face sessions was significantly different (P<0.01). There was a significant correlation (P<0.001) between attendance at e-learning and grade obtained at the faculty exam. Nevertheless, this correlation was also found for these students in another course taught traditionally. Overall, 309/315 (98%) students were satisfied with the blended teaching, 297/318 (93%) wanted its extent to the whole medical school's curriculum.
The use of combined learning methods reached more students than traditional teachings and allowed the University to focus on its role of knowledge transfer.
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