Around the tenth day after diagnosis, ~20% of patients with coronavirus disease 2019 (COVID-19)–associated pneumonia evolve toward severe oxygen dependence (stage 2b) and acute respiratory distress ...syndrome (stage 3) associated with systemic inflammation often termed a “cytokine storm.” Because interleukin-1 (IL-1) blocks the production of IL-6 and other proinflammatory cytokines, we treated COVID-19 patients early in the disease with the IL-1 receptor antagonist, anakinra.We retrospectively compared 22 patients from three different centers in France with stages 2b and 3 COVID-19–associated pneumonia presenting with acute severe respiratory failure and systemic inflammation who received either standard-of-care treatment alone (10 patients) or combined with intravenous anakinra (12 patients). Treatment started at 300 mg·d−1 for 5 d, then tapered with lower dosing over 3 d. Both populations were comparable for age, comorbidities, clinical stage, and elevated biomarkers of systemic inflammation. All of the patients treated with anakinra improved clinically (P < 0.01), with no deaths, significant decreases in oxygen requirements (P < 0.05), and more days without invasive mechanical ventilation (P < 0.06), compared with the control group. The effect of anakinra was rapid, as judged by significant decrease of fever and C-reactive protein at day 3. A mean total dose of 1,950 mg was infused with no adverse side effects or bacterial infection. We conclude that early blockade of the IL-1 receptor is therapeutic in acute hyperinflammatory respiratory failure in COVID-19 patients.
Hyperoxia is common during liver transplantation (LT), without being supported by any guidelines. Recent studies have shown the potential deleterious effect of hyperoxia in similar models of ...ischemia-reperfusion. Hyperoxia after graft reperfusion during orthotopic LT could increase lactate levels and worsen patient outcomes.
We conducted a retrospective and monocentric pilot study. All adult patients who underwent LT from 26 July 2013 to 26 December 2017 were considered for inclusion. Patients were classified into two groups according to oxygen levels before graft reperfusion: the hyperoxic group (PaO
> 200 mmHg) and the nonhyperoxic group (PaO
< 200 mmHg). The primary endpoint was arterial lactatemia 15 min after graft revascularization. Secondary endpoints included postoperative clinical outcomes and laboratory data.
A total of 222 liver transplant recipients were included. Arterial lactatemia after graft revascularization was significantly higher in the hyperoxic group (6.03 ± 4 mmol/L) than in the nonhyperoxic group (4.81 ± 2 mmol/L),
< 0.01. The postoperative hepatic cytolysis peak, duration of mechanical ventilation and duration of ileus were significantly increased in the hyperoxic group.
In the hyperoxic group, the arterial lactatemia, the hepatic cytolysis peak, the mechanical ventilation and the postoperative ileus were higher than in the nonhyperoxic group, suggesting that hyperoxia worsens short-term outcomes and could lead to increase ischemia-reperfusion injury after liver transplantation. A multicenter prospective study should be performed to confirm these results.
Objectives: To describe clinical characteristics and management of intensive care units (ICU) patients with laboratory-confirmed COVID-19 and to determine 90-day mortality after ICU admission and ...associated risk factors. Methods: This observational retrospective study was conducted in six intensive care units (ICUs) in three university hospitals in Marseille, France. Between 10 March and 10 May 2020, all adult patients admitted in ICU with laboratory-confirmed SARS-CoV-2 and respiratory failure were eligible for inclusion. The statistical analysis was focused on the mechanically ventilated patients. The primary outcome was the 90-day mortality after ICU admission. Results: Included in the study were 172 patients with COVID-19 related respiratory failure, 117 of whom (67%) received invasive mechanical ventilation. 90-day mortality of the invasively ventilated patients was 27.4%. Median duration of ventilation and median length of stay in ICU for these patients were 20 (9–33) days and 29 (17–46) days. Mortality increased with the severity of ARDS at ICU admission. After multivariable analysis was carried out, risk factors associated with 90-day mortality were age, elevated Charlson comorbidity index, chronic statins intake and occurrence of an arterial thrombosis. Conclusion: In this cohort, age and number of comorbidities were the main predictors of mortality in invasively ventilated patients. The only modifiable factor associated with mortality in multivariate analysis was arterial thrombosis.
To determine the effect on the occurrence of urosepsis of a treatment with a short course of antibiotics and indwelling urethral catheter replacement in clinically asymptomatic intensive care unit ...(ICU) patients with a positive urine culture occurring at least 48 h after catheterization.
A prospective randomized clinical trial was conducted in the medico-surgical ICU of a tertiary care centre. Sixty patients hospitalized in the ICU with an indwelling urethral catheter for longer than 48 h developing an asymptomatic positive urine culture were randomized to receive either a 3-day course of antibiotics associated with the replacement of the indwelling urethral catheter 4 h after first antibiotic administration or no antibiotics, no catheter replacement (standard of care).
Three patients in each group developed urosepsis (P=0.1). There were no significant differences in duration of mechanical ventilation between the study group and the standard of care group (9 4-20 days vs 5 2-15 days, P=0.2), in duration of urinary catheterization (22 11-40 days vs 18 14-33 days, P=0.8), or in length of ICU stay (28 13-46 vs 19 15-34, P=0.6). The recurrence of positive urine culture at days 7 and 15 was not affected by the randomization (P=0.1). The profile of bacterial resistance was similar in the two groups.
Treating a positive urine culture in an asymptomatic patient with an indwelling urethral catheter does not reduce the occurrence of urosepsis in the medico-surgical ICU.
Growing evidence suggests that the microvascular dysfunction is the key element of the pathogenesis of septic shock. This study's purpose was to explore whether the outcome of septic shock patients ...after early resuscitation using early goal-directed therapy is related to their muscle tissue oxygenation.
Tissue oxygen saturation (Sto2) was monitored in septic shock patients using a tissue spectrometer (InSpectra Model 325; Hutchinson Technology, Hutchinson, MN). For the purpose of this retrospective study, the Sto2 values were collected at the first measurement done after the macrohemodynamic variables (mean arterial pressure, urine output, central venous saturation in oxygen) were optimized.
After the hemodynamic variables were corrected, no difference was observed between the nonsurvivors and survivors, with the exception of pulse oximetry saturation (94% 92-97% vs. 97% 94-99%, P = 0.04). The Sto2 values were significantly lower in the nonsurvivors than in the survivors (73% 68-82% vs. 84% 81-90%, P = 0.02). No correlations were found between the Sto2 and Spo2 (P = 0.7).
In septic shock patients, tissue oxygen saturation below 78% is associated with increased mortality at day 28. Further investigations are required to determine whether the correction of an impaired level of tissue oxygen saturation may improve the outcome of these patients.
Background
Chronic kidney disease (CKD) is a frequent long-term complication after liver transplantation (LT) and is associated with poor long-term survival. The aim of our study was to identify the ...risk factors of developing post-transplant CKD at 1 year, during the pre-operative, peri-operative, and post-LT phases.
Methods
All consecutive patients who underwent primary LT between July 2013 and February 2018 were analyzed
.
To assess the impact of peri- and post-operative factors on renal function at 1 year we performed a propensity score matching on gender, age of the recipient, Model for End-Stage Liver Disease (MELD) score, etiology of the hepatic disease, and estimated Glomerular Filtration Rate (eGFR) at baseline.
Results
Among the 245 patients who underwent LT, 215 had available data at one year (Y1), and 46% of them had CKD. Eighty-three patients in the CKD group and 83 in the normal renal function group were then matched. The median follow-up was 35 months (27–77). Patients with CKD at Y1 had a decreased 5-year survival compared to patients with normal renal function at one year: figures were 62% and 90%, respectively,
p
= 0.001. The independent predictors of CKD at Y1 were major complications (OR = 2.2, 95% CI 1.2–4.2),
p
= 0.015, intensive care unit (ICU) stay > 5 days (OR = 2.2, 95% CI 1.3–5.1),
p
= 0.046, ICU serum lactate level at 24 h ≥ 2.5 mmol/L (OR = 3.8 95% CI 1.1–8),
p
= 0.034, need for post-LT renal replacement therapy (OR = 6.4 95% CI 1.4–25), and MELD score ≥ 20 (OR = 2.1 95% CI 1.1–3.9),
p
= 0.019.
Conclusions
The peri-operative period has a major impact on CKD incidence. Early recognition of patients at high risk of CKD may be critical for implementation of nephroprotective measures.
Graphic abstract
Abstract
Background
Acute pancreatitis after liver resection is a rare but serious complication, and few cases have been described in the literature. Extended lymphadenectomy, and long ischemia due ...to the Pringle maneuver could be responsible of post-liver resection acute pancreatitis, but the exact causes of AP after hepatectomy remain unclear.
Cases presentation
We report here three cases of AP after hepatectomy and we strongly hypothesize that this is due to the bile leakage white test. 502 hepatectomy were performed at our center and 3 patients (0.6%) experienced acute pancreatitis after LR and all of these three patients underwent the white test at the end of the liver resection. None underwent additionally lymphadenectomy to the liver resection. All patient had a white-test during the liver surgery. We identified distal implantation of the cystic duct in these three patients as a potential cause for acute pancreatitis.
Conclusion
The white test is useful for detection of bile leakage after liver resection, but we do not recommend a systematic use after LR, because severe acute pancreatitis can be lethal for the patient, especially in case of distal cystic implantation which may facilitate reflux in the main pancreatic duct.
Hypoxia-inducible factor-1 (HIF1) controls the expression of genes involved in the cellular response to hypoxia. No information is available on its expression in critically ill patients. Thus, we ...designed the first clinical study in order to evaluate the role of HIF1α as a prognosis marker in patients with shock.
50 consecutive adult patients with shock and 11 healthy volunteers were prospectively included. RNA was extracted from whole blood samples and expression of HIF1α was assessed over the first 4 hours of shock. The primary objective was to assess HIF1α as a prognostic marker in shock. Secondary objectives were to evaluate the role of HIF1α as a diagnostic and follow-up marker. Patient survival was evaluated at day 28.
The causes of shock were sepsis (78%), hemorrhage (18%), and cardiac dysfunction (4%). The HIF1α expression was significantly higher in the shock patients than in the healthy volunteers (121 72-168 vs. 48 38-54 normalized copies, p < 0.01), whatever the measured isoforms. It was similar in non-survivors and survivors (108 range 84-183 vs. 121 range 72-185 normalized copies, p = 0.92), and did not significantly change within the study period.
The present study is the first to demonstrate the increased expression of HIF1α in patients with shock. Further studies are needed to clarify the potential association with outcome. Our findings reinforce the value of monitoring plasma lactate levels to guide the treatment of shock.
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