An anisocoria that does not look right Saade, Anastasia; Tudesq, Jean-Jacques; Dumas, Guillaume ...
Intensive care medicine,
09/2020, Volume:
46, Issue:
9
Journal Article
Peer reviewed
A 27-year-old man was admitted to the intensive care unit (ICU) for septic shock secondary to right upper lobe community-acquired pneumonia. Neurological exam was normal. ICU stay was complicated by ...severe acute respiratory distress syndrome requiring invasive mechanical ventilation. Extubation after sedation discontinuation occurred at day 5. Neurological revaluation at day 6 revealed anisocoria with right miosis and ptosis associated with left mydriasis, eyelid retraction and exophtalmia (Fig. 1).
Anti-CD19 chimeric antigen receptor (CAR) T-cells represent a major advance in the treatment of relapsed/refractory aggressive B-cell lymphomas. However, a significant number of patients experience ...failure. Among 550 patients registered in the French registry DESCAR-T, 238 (43.3%) experienced progression/relapse, with a median follow-up of 7.9 months. At registration, 57.0% of patients presented an age-adjusted International Prognostic Index of 2 to 3, 18.9% had Eastern Cooperative Oncology Group performance status ≥2, 57.1% received >3 lines of treatment prior to receiving CAR T-cells, and 87.8% received bridging therapy. At infusion, 66% of patients presented progressive disease, and 38.9% had high lactate dehydrogenase (LDH). Failure after CAR T-cell treatment occurred after a median of 2.7 months (range: 0.2-21.5). Fifty-four patients (22.7%) presented very early failure (day D 0-D30); 102 (42.9%) had early failure (D31-D90), and 82 (34.5%) had late (>D90) failure. After failure, 154 patients (64%) received salvage treatment: 38.3% received lenalidomide, 7.1% bispecific antibodies, 21.4% targeted treatment, 11% radiotherapy, and 20% immunochemotherapy with various regimens. Median progression-free survival was 2.8 months, and median overall survival (OS) was 5.2 months. Median OS for patients failing during D0-D30 vs after D30 was 1.7 vs 3.0 months, respectively (P = .0001). Overall, 47.9% of patients were alive at 6 months, but only 18.9% were alive after very early failure. In multivariate analysis, predictors of OS were high LDH at infusion, time to CAR-T failure <D30, and high C-reactive protein at infusion. This multicentric analysis confirms the poor outcome of patients relapsing after CAR T-cell treatment, highlighting the need for further strategies dedicated to this population.
Studies performed in spontaneously breathing patients with mild to moderate respiratory failure suggested that prone position (PP) in COVID-19 could be beneficial.
Consecutive critically ill patients ...with COVID-19 were enrolled in four ICUs. PP sessions lasted at least 3 h each and were performed twice daily. A Cox proportional hazard model identified factors associated with the need of intubation. A propensity score overlap weighting analysis was performed to assess the association between spontaneous breathing PP (SBPP) and intubation.
Among 379 patients, 40 underwent SBPP. Oxygenation was achieved by high flow nasal canula in all but three patients. Duration of proning was 2.5 1.6;3.4 days. SBPP was well tolerated hemodynamically, increased PaO2/FiO2 (78 68;96 versus 63 53;77 mm Hg, p = 0.004) and PaCO2 (38 34;43 versus 35 32;38 mm Hg, p = 0.005). Neither day-28 survival (HR 0.51, 95% CI 0.16–1.16 nor risk of invasive ventilation sHR 0.96; 95% CI 0.49;1.88 differed between patients who underwent PP and others.
SBPP in COVID-19 is feasible and well tolerated in severely hypoxemic patients. It did not induce any effect on risk of intubation and day-28 mortality.
•Our study reports that prone position performed in non-intubated spontaneously breathing patients with severe respiratory failure due to COVID-19 was performed in 10.5% of cases in a large cohort of 379 consecutive patients in 4 university centres.•This strategy was well-tolerated, significantly improved blood gas exchange and was not associated with the risk of intubation and mortality.
Coronavirus disease 2019 (COVID-19) -associated pulmonary aspergillosis (CAPA) has emerged as a complication in critically ill COVID-19 patients. The objectives of this multinational study were to ...determine the prevalence of CAPA in patients with COVID-19 in intensive care units (ICU) and to investigate risk factors for CAPA as well as outcome.
The European Confederation of Medical Mycology (ECMM) conducted a multinational study including 20 centres from nine countries to assess epidemiology, risk factors and outcome of CAPA. CAPA was defined according to the 2020 ECMM/ISHAM consensus definitions.
A total of 592 patients were included in this study, including 11 (1.9%) patients with histologically proven CAPA, 80 (13.5%) with probable CAPA, 18 (3%) with possible CAPA and 483 (81.6%) without CAPA. CAPA was diagnosed a median of 8 days (range 0–31 days) after ICU admission predominantly in older patients (adjusted hazard ratio (aHR) 1.04 per year; 95% CI 1.02–1.06) with any form of invasive respiratory support (HR 3.4; 95% CI 1.84–6.25) and receiving tocilizumab (HR 2.45; 95% CI 1.41–4.25). Median prevalence of CAPA per centre was 10.7% (range 1.7%–26.8%). CAPA was associated with significantly lower 90-day ICU survival rate (29% in patients with CAPA versus 57% in patients without CAPA; Mantel–Byar p < 0.001) and remained an independent negative prognostic variable after adjusting for other predictors of survival (HR 2.14; 95% CI 1.59–2.87, p ≤ 0.001).
Prevalence of CAPA varied between centres. CAPA was significantly more prevalent among older patients, patients receiving invasive ventilation and patients receiving tocilizumab, and was an independent strong predictor of ICU mortality.
Background
Empirical antibiotic has been considered in severe COVID-19 although little data are available regarding concomitant infections. This study aims to assess the frequency of infections, ...community and hospital-acquired infections, and risk factors for infections and mortality during severe COVID-19.
Methods
Retrospective single-center study including consecutive patients admitted to the intensive care unit (ICU) for severe COVID-19. Competing-risk analyses were used to assess cumulative risk of infections. Time-dependent Cox and fine and gray models were used to assess risk factors for infections and mortality. Propensity score matching was performed to estimate the effect of dexamethasone.
Results
We included 100 patients including 34 patients with underlying malignancies or organ transplantation. First infectious event was bacterial for 35 patients, and fungal for one. Cumulative incidence of infectious events was 27% 18–35 at 10 ICU-days. Prevalence of community-acquired infections was 7% 2.8–13.9. Incidence density of hospital-acquired infections was 125 91–200 events per 1000 ICU-days. Risk factors independently associated with hospital-acquired infections included MV. Patient’s severity and underlying malignancy were associated with mortality. Dexamethasone was associated with increased infections (36% 20–53 vs. 12% 4–20 cumulative incidence at day-10;
p
= 0.01). After matching, dexamethasone was associated with hospital-acquired infections (35% 18–52 vs. 13% 1–25 at 10 days, respectively,
p
= 0.03), except in the subset of patients requiring MV, and had no influence on mortality.
Conclusions
In this population of COVID-19 patients with high prevalence of underlying immune defect, a high risk of infections was noted. MV and use of steroids were independently associated with infection rate.
Invasive pulmonary aspergillosis (IPA) is a fungal infection that is the hallmark of severe cellular or complex immune alterations. Evidence that IPA can occur in nonimmunocompromised hosts is ...increasing. Actually, up to 1% of general intensive care unit (ICU) patients present positive samples with
spp. Both colonization and invasive disease are associated with poor outcome. Unexpected IPA has also been reported in approximately 1% of critically ill patients who underwent postmortem biopsies. In nonimmunocompromised patients with acute respiratory distress syndrome (ARDS), IPA prevalence can reach up to 15% of patients in both clinical and autopsy studies. Factors associated with IPA in nonimmunocompromised critically ill hosts include short and long courses of steroids, broad antibiotic therapy, chronic obstructive pulmonary disease, ARDS, liver failure, and the severity of organ dysfunctions.This review aims to appraise the prevalence of IPA in nonimmunocompromised hosts, address diagnostic challenges, and outcomes.
Background Coagulation disorders are common in patients with hemophagocytic lymphohistiocytosis (HLH), associated with an increased risk of bleeding and death. We aim to investigate coagulation ...disorders and their outcome implications in critically ill patients with HLH. Methods We prospectively evaluated 47 critically ill patients with HLH (median age of 54 years 42-67) between April 2015 and December 2018. Coagulation assessments were performed at day 1. Abnormal standard coagulation was defined as prothrombin time (PT) <50% and/or fibrinogen <2g/L. HLH aetiology was mostly ascribed to haematological malignancies (74% of patients). Results Coagulation disorders and severe bleeding events were frequent, occurring in 30 (64%) and 11 (23%) patients respectively. At day 1, median fibrinogen level was 2â65g/L 1.61-5.66. Fibrinolytic activity was high as suggested by increased median levels of D-dimers, fibrin monomers, PAI-1 (plasminogen activator inhibitor) and tPA (tissue plasminogen activator). Forty-one (91%) patients had a decreased ADAMTS13 activity (A Disintegrin-like And Metalloproteinase with ThromboSpondin type 1 repeats, member 13). By multivariable analysis, the occurrence of a severe bleeding (OR 3.215 1.194-8.653, p = 0â021) and SOFA score (Sepsis-Related Organ Failure Assessment) at day 1 (OR 1.305 per point 1.146-1.485, p<0â001) were independently associated with hospital mortality. No early biological marker was associated with severe bleeding. Conclusions Hyperfibrinolysis may be the primary mechanism responsible for hypofibrinogenemia and may also participate in ADAMTS13 degradation. Targeting the plasmin system appears as a promising approach in severe HLH-related coagulation disorders.
Background
A higher sodium (Na) dialysate concentration is recommended during renal replacement therapy (RRT) of acute kidney injury (AKI) to improve intradialytic hemodynamic tolerance, but it may ...lead to Na loading to the patient. We aimed to evaluate Na flux according to Na dialysate and infusate concentrations at 140 and 145 mmol/L during hemodialysis (HD) and hemodiafiltration (HDF).
Methods
Fourteen AKI patients that underwent consecutive HD or HDF sessions with Na dialysate/infusate at 140 and 145 mmol/L were included. Per‐dialytic flux of Na was estimated using mean sodium logarithmic concentration including diffusive and convective influx. We compared the flux of sodium between HD140 and 145, and between HDF140 and 145.
Results
Nine HD140, ten HDF140, nine HD145, and 11 HDF145 sessions were analyzed. A Na gradient from the dialysate/replacement fluid to the patient was observed with dialysate/infusate Na at 145 mmol/L in both HD and HDF (p = 0.01). The comparison of HD145 to HD140 showed that higher Na dialysate induced a diffusive Na gradient to the patient (163 mmol vs. −25 mmol, p = 0.004) and that of HDF145 to −140 (211 vs. 36 mmol, p = 0.03) as well. Intradialytic hemodynamic tolerance was similar across all RRT sessions.
Conclusions
During both HD and HDF, a substantial Na loading occurred with a Na dialysate and infusate at 145 mmol/L. This Na loading is smaller in HDF with Na dialysate and infusate concentration at 140 mmol/L and inversed with HD140. Clinical and intradialytic hemodynamic tolerance was fair regardless of Na dialysate and infusate.
Clinical and intradialytic hemodynamic tolerance was fair regardless of Na dialysate and infusate. However, both intermittent HD and HDF with a Na dialysate and infusate set at 145 mmol/L will induce a Na overload to the patient.
Cancer affects up to 20% of critically ill patients, and sepsis is one of the leading reasons for ICU admission in this setting. Early signals suggested that survival might be increasing in this ...population. However, confirmation studies have been lacking. The goal of this study was to assess trends in survival rates over time in cancer patients admitted to the ICU for sepsis or septic shock over the last 2 decades.
Seven European ICUs.
A hierarchical model taking into account the year of admission and the source dataset as random variables was used to identify risk factors for day 30 mortality.
Data from cancer patients admitted to ICUs for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique database (1994-2015).
Overall, 2,062 patients (62% men, median interquartile range age 59 yr 48-67 yr) were included in the study. Underlying malignancies were solid tumors (n = 362; 17.6%) or hematologic malignancies (n = 1,700; 82.4%), including acute leukemia (n = 591; 28.7%), non-Hodgkin lymphoma (n = 461; 22.3%), and myeloma (n = 244; 11.8%). Two-hundred fifty patients (12%) underwent allogeneic hematopoietic stem cell transplantation and 640 (31.0%) were neutropenic at ICU admission. Day 30 mortality was 39.9% (823 deaths). The year of ICU admission was associated with significant decrease in day 30 mortality over time (odds ratio, 0.96; 95% CI, 0.93-0.98; p = 0.001). Mechanical ventilation (odds ratio, 3.25; 95% CI, 2.52-4.19; p < 0.01) and vasopressors use (odds ratio, 1.42; 95% CI, 1.10-1.83; p < 0.01) were independently associated with day 30 mortality, whereas underlying malignancy, allogeneic hematopoietic stem cell transplantation, and neutropenia were not.
Survival in critically ill oncology and hematology patients with sepsis improved significantly over time. As outcomes improve, clinicians should consider updating admission policies and goals of care in this population.
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