Objective
To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU).
Background
POCUS is of growing importance in the ICU. ...Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown.
Methods
Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified.
Results
Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts.
Conclusions
With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.
Background An association was reported between the left ventricular longitudinal strain (LV-LS) and preload. LV-LS reflects the left cardiac function curve as it is the ratio of shortening over ...diastolic dimension. The aim of this study was to determine the sensitivity and specificity of LV-LS variations after a passive leg raising (PLR) maneuver to predict fluid responsiveness in intensive care unit (ICU) patients with acute circulatory failure (ACF). Methods Patients with ACF were prospectively included. Preload-dependency was defined as a velocity time integral (VTI) variation greater than 10% between baseline (T0) and PLR (T1), distinguishing the preload-dependent (PLD+) group and the preload-independent (PLD-) group. A 7-cycles, 4-chamber echocardiography loop was registered at T0 and T1, and strain analysis was performed off-line by a blind clinician. A general linear model for repeated measures was used to compare the LV-LS variation (T0 to T1) between the two groups. Results From June 2018 to August 2019, 60 patients (PLD+ = 33, PLD- = 27) were consecutively enrolled. The VTI variations after PLR were +21% (±8) in the PLD+ group and -1% (±7) in the PLD- group (p<0.01). Mean baseline LV-LS was -11.3% (±4.2) in the PLD+ group and -13.0% (±4.2) in the PLD- group (p = 0.12). LV-LS increased in the whole population after PLR +16.0% (±4.0) (p = 0.04). The LV-LS variations after PLR were +19.0% (±31) (p = 0.05) in the PLD+ group and +11.0% (±38) (p = 0.25) in the PLD- group, with no significant difference between the two groups (p = 0.08). The area under the curve for the LV-LS variations between T0 and T1 was 0.63 0.48-0.77. Conclusion Our study confirms that LV-LS is load-dependent; however, the variations in LV-LS after PLR is not a discriminating criterion to predict fluid responsiveness of ICU patients with ACF in this cohort.
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.
Purpose
Diagnosis and treatment of AMI are a real issue for implicating physicians. In the literature, only one AMI stroke center has reported its results so far, with increasing survival rates. Our ...aim was to analyze acute mesenteric ischemia (AMI) related mortality and predictive factors, in a single academic center, before creating a dedicated intestinal stroke center.
Methods
All the patients with an AMI, between January 2015 and December 2020, were retrospectively included. They were divided into 2 groups according to the early mortality: death during the first 30 days and alive. The 2 groups were compared.
Results
173 patients (57% of men), were included, with a mean age of 68 ± 16 years. Overall mortality rate was 61%. Mortality occurred within the first 30 days in 78% of dead cases. Dead patients were significantly older, more frequently admitted from intensive care, with more serious clinical, laboratory and radiological characteristics. We have identified 3 protective factors - history of abdominal surgery (Odd Ratio = 0.1; 95%CI = 0.01–0.8, p = 0.03), medical management with curative anticoagulation (OR = 0.09; 95%CI = 0.02–0.5, p = 0.004) and/or antiplatelets (OR = 0.04; 95%CI = 0.006–0.3, p = 0.001)-, and 2 predictive factors of mortality – age > 70 years (OR = 7; 95%CI = 1.4–37, p = 0.02) and previous history of coronaropathy (OR = 13; 95%CI = 1.7–93, p = 0.01).
Conclusions
AMI is a severe disease with high morbidity and mortality rates. Even if its diagnosis is still difficult because of non-specific presentation, its therapeutic management needs to be changed in order to improve survival rates, particularly in patients older than 70 years with history of coronaropathy. Developing a dedicated organization would improve the diagnosis and the management of patients with AMI.
Cirrhotic cardiomyopathy (CCM) is a major comorbidity of cirrhosis. The diagnostic performance of conventional echocardiography is poor. Two-dimensional-strain echo-cardiography (2D-strain) detects ...myocardial dysfunction earlier than conventional echocardiography, with a significant prognostic value. The aim of our study is to assess whether the 2D-strain will allow a more relevant assessment of CCM in cirrhotic patients than conventional echocardiography. The secondary objective is to determine if altered strain or strain rate are associated with cirrhotic patient's outcome in intensive care unit (ICU).
Conventional echocardiography and 2D-strain were performed on 44 consecutive patients within 24 hours of admission to the ICU. Using 2D-strain, the global-longitudinal-strain (GLS) was assessed.
GLS was impaired in 64% of patients. GLS was significantly higher in the patients who died compared with those who survived, using 28-day mortality rate (-17 vs -14 p < 0.039). Regarding conventional echocardiography, no factor was associated with increased mortality.
GLS is correlated to cirrhotic patient's prognosis in intensive care, while conventional echocardiography shows no dysfunction.
Acute severe hepatitis is a rare complication of adult-onset Still’s disease (AOSD). This condition is poorly characterized. We performed a review of the medical literature to describe clinical, ...biological, pathological, and treatment characteristics from AOSD patients with acute severe hepatitis. Their characteristics were compared with AOSD patients without severe hepatitis. Twenty-one cases were collected including a new case reported here. Patients with severe hepatitis were mostly young adults with a median age of 28 years (range: 20 to 55 years). Overall, patients with severe hepatitis had less arthritis, macular rash, sore throat, lymphadenopathy, or splenomegaly than patients without severe hepatitis. Cytopenia was more frequent in case of severe hepatitis. Most patients were treated with steroids, and the use of biotherapies has increased over the last decade. Despite treatment, 49% of patients required liver transplantation and 24% died.
Key Points
•
Acute severe hepatitis in adult-onset Still’s disease (AOSD) is associated with liver transplantation and/or death in, respectively, 43% and 24% of cases
.
•
Severe hepatitis is the inaugural manifestation of AOSD in half of cases. Diagnosis is difficult when extra-hepatic clinical manifestations are lacking.
•
The mechanism of hepatic necrosis in AOSD with severe hepatitis is unknown. Liver biopsy is not specific and should not delay treatment initiation.
Objective
In a cohort of mechanically ventilated patients to compare the automatic tidal volume (
V
T
)–respiratory rate (RR) combination generated by adaptive support ventilation (ASV) for various ...lung conditions.
Design and setting
Prospective observational cohort study in the 11-bed medicosurgical ICU of a general hospital.
Patients
243 patients receiving 1327 days of invasive ventilation on ASV.
Measurements
Daily collection of ventilator settings, breathing pattern, arterial blood gases, and underlying clinical respiratory conditions categorized as: normal lungs, ALI/ARDS, COPD, chest wall stiffness, or acute respiratory failure.
Results
Overall the respiratory mechanics differed significantly with the underlying conditions. In passive patients ASV delivered different
V
T
–RR combinations based on the underlying condition, providing higher
V
T
and lower RR in COPD than in ALI/ARDS: 9.3 ml/kg (8.2–10.8) predicted body weight (PBW) and 13 breaths/min (11–16) vs. 7.6 ml/kg (6.7–8.8) PBW and 18 breaths/min (16–22). In patients actively triggering the ventilator the
V
T
–RR combinations did not differ between COPD, ALI/ARDS, and normal lungs.
Conclusions
ASV selects different
V
T
–RR combinations based on respiratory mechanics in passive, mechanically ventilated patients.
Sleep disorders can affect the health of physicians and patient outcomes.
To determine the prevalence of sleep disorders among French anaesthesiologists and intensivists working in a public hospital.
...A cross-sectional survey.
Anaesthesiologists and intensivists working in French public hospitals.
Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS) was used to assess the degree of excessive daytime sleepiness.
Among 1504 responders, 677 (45%) physicians reported sleep disorders. The independent factors associated with sleep disorders were reporting of sleep disorders odds ratio (OR) 12.04, 95% CI (95% confidence interval) 8.89 to 16.46, sleep time less than 7 h (OR 8.86, 95% CI 6.50 to 12.20), work stress (OR 2.04, 95% CI 1.49 to 2.83), stress at home (OR 1.77, 95% CI 1.24 to 2.53), anxiolytic use (OR 3.69, 95% CI 2.23 to 6.25), psychotropic drug use (OR 3.91, 95% CI 1.51 to 11.52) and excessive daytime sleepiness (OR 1.81, 95% CI 1.34 to 2.45). Six hundred and seventy-six (44%) responders reported excessive daytime sleepiness during their professional activity. The independent factors associated with excessive daytime sleepiness were female sex (OR 1.86, 95% CI 1.49 to 2.34), tea consumption (OR 1.47, 95% CI 1.14 to 1.91), regular practice of nap (OR 1.68, 95% CI 1.34 to 2.09), stress at home (OR 1.31, 95% CI 1.02 to 1.68), more than four extended work shifts monthly (OR 1.25, 95% CI 1.01 to 1.56) and sleep disorders (OR 1.73, 95% CI 1.31 to 2.29). Reporting sleep disorder duration and a sleep time less than 7 h were the two major risk factors for sleep disorders. Female sex was the major risk factor for excessive daytime sleepiness.
French anaesthesiologists did not report more sleep disorders than the general population, but their alertness is impaired by a factor of two.
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