Effects of mean arterial pressure on arousal in sedated ventilated patients with septic shock: a SEPSISPAM post hoc exploratory study.

BACKGROUND: It is unknown whether the recommended mean arterial pressure (MAP) target of 65 mmHg during initial resuscitation of septic shock is sufficient to maintain cerebral perfusion. Thus, we tested the hypothesis that a higher MAP target in patients with septic shock may improve level of arousal. METHODS: We performed a post hoc exploratory analysis of the SEPSISPAM trial, which assessed the effect of a "high-target" level of MAP (80-85 mmHg) versus the recommended "low-target" MAP (65-70 mm Hg) on mortality in patients with septic shock. Among the 776 patients originally recruited in SEPSISPAM trial, we selected those who were mechanically ventilated and sedated and with available evaluation of arousal level assessed by the Richmond Agitation and Sedation Scale (RASS). RESULTS: We restricted our analysis to the period in which patients were treated with vasoactive drugs. Cumulative sedative drugs were assessed daily. A total of 532 patients were included in this study: 253 (47.6%) in the low-target group and 279 (52.4%) in the high-target group. Daily cumulative sedative drugs were similar in both groups. Compared to the low-target group, minimal and maximal RASS were significantly higher in the high-target group at day 2, 4 and 5. Furthermore, in order to consider the fact that multiple measures were done for each patient and to consider the global effect of time on these measures, we used a mixed linear regression and multivariate models: we confirmed that maximal RASS values were significantly higher in the high-target group. CONCLUSION: In patients with septic shock who were mechanically ventilated and sedated, resuscitation with MAP target between 80 and 85 mmHg was associated with higher arousal level as compared to a MAP target between 65 and 70 mmHg.

High versus low blood-pressure target in patients with septic shock.

BACKGROUND: The Surviving Sepsis Campaign recommends targeting a mean arterial pressure of at least 65 mm Hg during initial resuscitation of patients with septic shock. However, whether this blood-pressure target is more or less effective than a higher target is unknown. METHODS: In a multicenter, open-label trial, we randomly assigned 776 patients with septic shock to undergo resuscitation with a mean arterial pressure target of either 80 to 85 mm Hg (high-target group) or 65 to 70 mm Hg (low-target group). The primary end point was mortality at day 28. RESULTS: At 28 days, there was no significant between-group difference in mortality, with deaths reported in 142 of 388 patients in the high-target group (36.6%) and 132 of 388 patients in the low-target group (34.0%) (hazard ratio in the high-target group, 1.07; 95% confidence interval [CI], 0.84 to 1.38; P=0.57). There was also no significant difference in mortality at 90 days, with 170 deaths (43.8%) and 164 deaths (42.3%), respectively (hazard ratio, 1.04; 95% CI, 0.83 to 1.30; P=0.74). The occurrence of serious adverse events did not differ significantly between the two groups (74 events [19.1%] and 69 events [17.8%], respectively; P=0.64). However, the incidence of newly diagnosed atrial fibrillation was higher in the high-target group than in the low-target group. Among patients with chronic hypertension, those in the high-target group required less renal-replacement therapy than did those in the low-target group, but such therapy was not associated with a difference in mortality. CONCLUSIONS: Targeting a mean arterial pressure of 80 to 85 mm Hg, as compared with 65 to 70 mm Hg, in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days. (Funded by the French Ministry of Health; SEPSISPAM ClinicalTrials.gov number, NCT01149278.).

Prognostic value of electrographic postanoxic status epilepticus in comatose cardiac-arrest survivors in the therapeutic hypothermia era.

BACKGROUND: The independent prognostic significance of postanoxic status epilepticus (PSE) has not been evaluated prospectively since the introduction of therapeutic hypothermia. We studied 1-year functional outcomes and their determinants in comatose survivors of cardiac arrest (CA), with special attention to PSE. METHODS: 106 comatose CA survivors admitted to the intensive care unit in 2005-2010 were included in a prospective observational study. The main outcome measure was a Cerebral Performance Category scale (CPC) of 1 or 2 (favorable outcome) 1 year after CA. RESULTS: CA occurred out-of-hospital in 89 (84%) patients and was witnessed from onset in 94 (89%). Median times were 6 min (IQR, 0-11) from CA to first-responder arrival and 23 min (14-40) from collapse to return of spontaneous circulation. PSE was diagnosed in 33 (31%) patients at a median of 39 h (4-49) after CA. PSE was refractory in 24 (22%) cases and malignant in 19 (20%). After 1 year, 31 (29.3%) patients had favorable outcomes including 2 (6.44%) with PSE. Factors independently associated with poor outcome (CPC ≥ 3) were PSE (odds ratio [OR], 14.28; 95% confidence interval [95% CI], 2.77-50.0; P=0.001), time to restoration of spontaneous circulation (OR, 1.04/min; 95% CI, 1-1.07; P=0.035), and LOD score on day 1 (OR, 1.28/point; 95% CI, 1.08-1.54; P=0.003). CONCLUSION: PSE strongly and independently predicts a poor outcome in comatose CA survivors receiving therapeutic hypothermia, but some patients with PSE survive with good functional outcomes. PSE alone is not sufficient to predict failure to awaken after CA in the era of therapeutic hypothermia.

Intermittent subglottic secretion drainage and ventilator-associated pneumonia: a multicenter trial.

RATIONALE: Ventilator-associated pneumonia (VAP) causes substantial morbidity and mortality. The influence of subglottic secretion drainage (SSD) in preventing VAP remains controversial. OBJECTIVES: To determine whether SSD reduces the overall incidence of microbiologically confirmed VAP. METHODS: Randomized controlled clinical trial conducted at four French centers. A total of 333 adult patients intubated with a tracheal tube allowing drainage of subglottic secretions and expected to require mechanical ventilation for ≥48 hours was included. Patients were randomly assigned to undergo intermittent SSD (n = 169) or not (n = 164). MEASUREMENTS AND MAIN RESULTS: Primary outcome was the overall incidence of VAP based on quantitative culture of distal pulmonary samplings performed after each clinical suspicion. Other outcomes included incidence of early- and late-onset VAP, duration of mechanical ventilation, and hospital mortality. Microbiologically confirmed VAP occurred in 67 patients, 25 of 169 (14.8%) in the SSD group and 42 of 164 (25.6%) in the control group (P = 0.02), yielding a relative risk reduction of 42.2% (95% confidential interval, 10.4-63.1%). Using the Day 5 threshold, the beneficial effect of SSD in reducing VAP was observed in both early-onset VAP (2 of 169 [1.2%] patients undergoing SSD vs. 10 of 164 [6.1%] control patients; P = 0.02) and late-onset VAP (23 of 126 [18.6%] patients undergoing SSD vs. 32 of 97 [33.0%] control patients; P = 0.01). VAP was clinically suspected at least once in 51 of 169 (30.2%) patients undergoing SSD and 60 of 164 (36.6%) control patients (P = 0.25). No significant between-group differences were observed in duration of mechanical ventilation and hospital mortality. CONCLUSIONS: Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late-onset VAP. Clinical trial registered with www.clinicaltrials.gov (NCT00219661).

Severe alcohol hand rub overdose inducing coma, watch after H1N1 pandemic.

BACKGROUND: Alcoholic hand rubs (AHRs) have been proven effective in preventing nosocomial infections, and healthcare authorities include AHRs use among quality-of-care criteria. Since the onset of the influenza A (H1N1) pandemic, AHRs have gained considerable popularity among the general public. METHODS: We report a case of intentional AHRs self-poisoning inducing rapid coma with hyperlactatemia, and a full recovery. The relevant literature was reviewed. To our knowledge, this is the third reported case of intentional AHRs poisoning. 3 patients presented with a picture of acute alcohol intoxication, of variable severity depending on the amount ingested and speed of ingestion. RESULTS: The blood alcohol level was 414 mg/dl and tests for other drugs were performed 30 min after admission. The blood lactate level increased briefly to 4.8 mmol/l, without renal or hepatic function disturbances. She regained consciousness after 6 h then achieved a full recovery allowing extubation and readmission to the psychiatric ward after 24 h. She reported gulping down the entire contents of the Aniosgel bottle. CONCLUSION: Whereas overdrinking in social settings (wine and liquor) leads to a gradual increase in blood alcohol levels, AHRs poisoning is usually characterized by a sudden massive alcohol load. The unusual nature of the alcohol source may lead to diagnostic wanderings. AHRs are currently available in bottles that facilitate the ingestion of large amounts. Unit-dose packaging or dispensing might decrease the risk of AHRs poisoning.

Early EEG monitoring for detecting postanoxic status epilepticus during therapeutic hypothermia: a pilot study.

OBJECTIVE: To determine whether routine electroencephalography (EEG) detected electrical status epilepticus (ESE), masked by neuromuscular blockade, in comatose cardiac-arrest survivors receiving therapeutic hypothermia. DESIGN: Prospective 3-year study. SETTING: Medical ICU. PATIENTS: Fifty-one consecutive comatose cardiac-arrest patients treated between May 2005 and May 2008 using a standardized protocol of hypothermia with neuromuscular blockade. INTERVENTION: EEG was performed routinely as soon as possible after starting therapeutic hypothermia. EEG recordings were read by an independent neurophysiologist who was blinded to patient data. MEASUREMENTS AND MAIN RESULTS: Median body temperature at EEG recording was 33.0°C (range 32.4-33.8). ESE was found on 5 (10%) of the 51 EEG recordings: three patients had continuous rhythmic generalized spikes and two patients had continuous rhythmic focal spike-waves. Of the 17 (33%) patients who were discharged alive, 8 (8/51, 16%) had a CPC score of 1, 4 (8%) of 2, and 5 (10%) of 3. All patients with ESE died during their ICU stay. CONCLUSION: These preliminary results indicate that postanoxic status epilepticus can be masked by neuromuscular blockade during our protocol of therapeutic hypothermia. Routine EEG monitoring might be helpful in cardiac-arrest survivors receiving therapeutic hypothermia. Further studies including continuous EEG monitoring are needed to determine whether early diagnosis and treatment of ESE during therapeutic hypothermia improves the outcome.

Recurrent takotsubo cardiomyopathy triggered by convulsive status epilepticus.

INTRODUCTION: Takotsubo cardiomyopathy can complicate several conditions including neurological emergencies. A few recurrent cases associated with seizures have been reported, but none of the patients had status epilepticus. The pathophysiology of takotsubo syndrome, although debated, may involve stunning of the myocardium by a catecholamine storm triggered by stress. Patients with epilepsy may be at increased risk for takotsubo syndrome, which may occur repeatedly. METHODS: We report on a postmenopausal woman with symptomatic epilepsy who experienced recurrent takotsubo cardiomyopathy triggered by convulsive status epilepticus. Brief seizures were not associated with takotsubo syndrome. The relevant literature was reviewed. RESULTS: Over a 1-year period, she experienced two episodes of convulsive status epilepticus with complete neurological recovery after treatment. Echocardiography showed latero-septo-apical hypokinesia and apical ballooning. The cardiac abnormalities resolved fully and she recovered her baseline level of self-sufficiency. During the same period, she experienced several brief seizures, with no cardiac manifestations. CONCLUSION: The occurrence of takotsubo cardiomyopathy in association with convulsive status epilepticus, but not with brief seizures, supports neurogenically mediated myocardial stunning related to direct toxicity of endogenous catecholamines. Neuro-intensivists must be aware of this potentially fatal but fully reversible cardiac complication, which may be among the causes of death in patients with status epilepticus.

Lysergic acid amide-induced posterior reversible encephalopathy syndrome with status epilepticus.

INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) is known to occur in association with several substances. However, lysergic acid amide (LSA) is not among the previously reported causes of PRES. METHODS: We report on a patient with PRES presenting as convulsive status epilepticus associated with hypertensive encephalopathy after LSA ingestion. Magnetic resonance imaging was performed and catecholamine metabolites assayed. RESULTS: The patient achieved a full recovery after aggressive antihypertensive therapy and intravenous anticonvulsivant therapy. The clinical history, blood and urinary catecholamine levels, and response to treatment strongly suggest that PRES was induced by LSA. CONCLUSION: LSA, a hallucinogenic agent chiefly used for recreational purposes, should be added to the list of causes of PRES.

Therapeutic hypothermia for coma after cardiorespiratory arrest caused by hanging.

We report a case in which mild therapeutic hypothermia was used successfully in a patient with coma after cardiorespiratory arrest induced by hanging.

Pneumomediastinum causing pneumoperitoneum during mechanical ventilation.

The causes of nonsurgical pneumoperitoneum include numerous diseases. We report here a case of nonsurgical pneumoperitoneum caused by benign pneumomediastinum during mechanical ventilation, and we discuss the anatomic pathways and the pathophysiologic mechanisms responsible for the development of this association.