Venous thromboembolism in critically Ill patients with COVID-19: Results of a screening study for deep vein thrombosis.

BACKGROUND: The rapid spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and coronavirus disease 2019 (COVID-19), has caused more than 3.9 million cases worldwide. Currently, there is great interest to assess venous thrombosis prevalence, diagnosis, prevention, and management in patients with COVID-19. OBJECTIVES: To determine the prevalence of venous thromboembolism (VTE) in critically ill patients with COVID-19, using lower limbs venous ultrasonography screening. METHODS: Beginning March 8, we enrolled 25 patients who were admitted to the intensive care unit (ICU) with confirmed SARS-CoV-2 infections. The presence of lower extremity deep vein thrombosis (DVT) was systematically assessed by ultrasonography between day 5 and 10 after admission. The data reported here are those available up to May 9, 2020. RESULTS: The mean (± standard deviation) age of the patients was 68 ± 11 years, and 64% were men. No patients had a history of VTE. During the ICU stay, 8 patients (32%) had a VTE; 6 (24%) a proximal DVT, and 5 (20%) a pulmonary embolism. The rate of symptomatic VTE was 24%, while 8% of patients had screen-detected DVT. Only those patients with a documented VTE received a therapeutic anticoagulant regimen. As of May 9, 2020, 5 patients had died (20%), 2 remained in the ICU (8%), and 18 were discharged (72%). CONCLUSIONS: In critically ill patients with SARS-CoV-2 infections, DVT screening at days 5-10 of admission yielded a 32% prevalence of VTE. Seventy-five percent of events occurred before screening. Earlier screening might be effective in optimizing care in ICU patients with COVID-19.

The Clinical Picture of Severe Systemic Capillary-Leak Syndrome Episodes Requiring ICU Admission.

OBJECTIVE: Systemic capillary-leak syndrome is a very rare cause of recurrent hypovolemic shock. Few data are available on its clinical manifestations, laboratory findings, and outcomes of those patients requiring ICU admission. This study was undertaken to describe the clinical pictures and ICU management of severe systemic capillary-leak syndrome episodes. DESIGN, SETTING, PATIENTS: This multicenter retrospective analysis concerned patients entered in the European Clarkson's disease (EurêClark) Registry and admitted to ICUs between May 1992 and February 2016. MEASUREMENTS AND MAIN RESULTS: Fifty-nine attacks occurring in 37 patients (male-to-female sex ratio, 1.05; mean ± SD age, 51 ± 11.4 yr) were included. Among 34 patients (91.9%) with monoclonal immunoglobulin G gammopathy, 20 (58.8%) had kappa light chains. ICU-admission hemoglobin and proteinemia were respectively median (interquartile range) 20.2 g/dL (17.9-22 g/dL) and 50 g/L (36.5-58.5 g/L). IV immunoglobulins were infused (IV immunoglobulin) during 15 episodes (25.4%). A compartment syndrome developed during 12 episodes (20.3%). Eleven (18.6%) in-ICU deaths occurred. Bivariable analyses (the 37 patients' last episodes) retained Sequential Organ-Failure Assessment score greater than 10 (odds ratio, 12.9 [95% CI, 1.2-140]; p = 0.04) and cumulated fluid-therapy volume greater than 10.7 L (odds ratio, 16.8 [1.6-180]; p = 0.02) as independent predictors of hospital mortality. CONCLUSIONS: We described the largest cohort of severe systemic capillary-leak syndrome flares requiring ICU admission. High-volume fluid therapy was independently associated with poorer outcomes. IV immunoglobulin use was not associated with improved survival; hence, their use should be considered prudently and needs further evaluation in future studies.

[Combination of hemodialysis and hemofiltration in severe caffeine intoxication]. / Intoxication sévère à la caféine traitée par hémodialyse et hémodiafiltration.

A 21-year-old man ingested 75g of pure caffeine, in an attempt to commit suicide. This represents 7.5 times the minimal lethal dose. Caffeine, 1,3,7-trimethylxanthine, is the most widely consumed psychoactive compound worldwide. It is mostly found in coffee, tea, energizing drinks and in some drugs. However, it has become really easy to obtain pure caffeine (powder or tablets) on the Internet. Mechanisms of action are dose-dependent. When caffeine overdosing occurs, neurologic, cardiovascular and renal systems are mainly affected. Severe intoxication can be fatal. No antidote is available and treatment is purely symptomatic. Hemoperfusion has previously been carried out in the 1990's to treat patients with caffeine intoxication. Since 2009, hemodialysis and hemofiltration have proposed as well. Our patient was successfully treated with a combination of hemodiafiltration, intermittent and then continuous.

Effect of stimulus type and temperature on EEG reactivity in cardiac arrest.

OBJECTIVE: Electroencephalogram (EEG) background reactivity is a reliable outcome predictor in cardiac arrest patients post therapeutic hypothermia. However, there is no consensus on modality testing and prior studies reveal only fair to moderate agreement rates. The aim of this study was to explore different stimulus modalities and report interrater agreements. METHODS: We studied a multicenter, prospectively collected cohort of cardiac arrest patients who underwent therapeutic hypothermia between September 2014 and December 2015. We identified patients with reactivity data and evaluated interrater agreements of different stimulus modalities tested in hypothermia and normothermia. RESULTS: Of the 60 patients studied, agreement rates were moderate to substantial during hypothermia and fair to moderate during normothermia. Bilateral nipple pressure is more sensitive (80%) when compared to other modalities in eliciting a reactive background in hypothermia. Auditory, nasal tickle, nailbed pressure and nipple pressure reactivity were associated with good outcomes in both hypothermia and normothermia. CONCLUSIONS: EEG reactivity varies depending on the stimulus testing modality as well as the temperature during which stimulation is performed, with nipple pressure emerging as the most sensitive during hypothermia for reactivity and outcome determination. SIGNIFICANCE: This highlights the importance of multiple stimulus testing modalities in EEG reactivity determination to reduce false negatives and optimize prognostication.

Prolonged catheter survival in patients with acute kidney injury on continuous renal replacement therapy using a less thrombogenic micropatterned polymer modification.

BACKGROUND: Continuous renal replacement therapy (CRRT) has been increasingly used in critically ill patients with acute kidney injury (AKI). One of the major properties that likely influence the catheter lifespan includes its surface specificity. We hypothesized that the improvement of blood-surface interaction by a reactive polymer film coating might reduce thrombogenic events in the vascular access device and subsequently lead to prolonged catheter survival in this clinical setting. METHODS: We compared, in a randomized study, the clinical application of two temporary catheters (TCs): one surface-modified double-lumen catheter (smDLC) and one standard sDLC with identical geometry and flow design. Efficacy end points were defined as the ability to complete at least 72 h CRRT without interruption due to TC dysfunction and ability to achieve blood flow rates of ≥150 mL/min. Safety end points were defined as the occurrence of catheter-related (CR) bacteraemia or other CR complications. RESULTS: We evaluated 236 critically ill patients (264 TCs) with AKI on CRRT (continuous venovenous haemodiafiltration) with age (mean±SD) of 56.9±17.9 years. The clinical investigation revealed that the number of hours before TC removal according to clinical requirements was significantly higher with smDLC as compared with sDLC (131±38 vs 113±21 h; P=0.004). Temporary catheter dysfunction occurred in 5% for smDLC and 14% for sDLC; P=0.001. Thrombosis of smDLC and sDLC was observed in 2.3 episodes per 1000 TC-days [95% confidence interval (CI), 1.9-2.5] and 4.2 episodes per 1000 TC-days (95% CI, 4.0-4.4), respectively; P=0.021. The blood flow rate was 221±29 mL/min vs 187±36 mL/min for smDLC and sDLC, respectively; P=0.012. Compared with the overall mean of TC dysfunction or thrombosis, the relative risk of premature removal (<72 h) was 0.43 (95% CI, 0.13-0.98; P=0.041) for smDLC and 2.51 (95% CI, 1.04-9.22; P=0.034) for sDLC with a significantly higher catheter-related bacteraemia rate in this latter group (P=0.008). CONCLUSION: Micropatterned surface coating with a polyurethane polymer significantly increased TC survival with lower dysfunction rate, lower thrombotic events and better bacteriological barrier than sDLC in critically ill patients with AKI necessitating CRRT.

[Cerbral salt wasting syndrome versus SIADH]. / Perte de sel d'origine cérébrale versus sécrétion inappropriée d'hormone antidiurétique.

In the context of cerebral diseases the two main mechanisms responsible for non iatrogenic causes of hyponatremia are cerebral salt wasting syndrome (CSW) and inappropriate secretion of antidiuretic hormone (SIADH). Distinction between these two syndromes is difficult and is based on the assessment of the patient's volume status. In case of CSW, the volume status is low and the treatment is fluid and sodium replacement. In case of SIADH the volume status is normal or slightly expanded and the treatment is fluid restriction. To avoid centropontine myelinolysis, the speed of correction should not exceed 8 to 10 mmol/L over a 24-hour period. This article will describe practical tools to differentiate CSW from SIADH and therapeutic strategies useful in daily clinical practice.

Development and simultaneous application of multiple care protocols in critical care: a multicenter feasibility study.

OBJECTIVE: To test the feasibility of and interactions among three software-driven critical care protocols. DESIGN: Prospective cohort study. SETTING: Intensive care units in six European and American university hospitals. PATIENTS: 174 cardiac surgery and 41 septic patients. INTERVENTIONS: Application of software-driven protocols for cardiovascular management, sedation, and weaning during the first 7 days of intensive care. MEASUREMENTS AND RESULTS: All protocols were used simultaneously in 85% of the cardiac surgery and 44% of the septic patients, and any one of the protocols was used for 73 and 44% of study duration, respectively. Protocol use was discontinued in 12% of patients by the treating clinician and in 6% for technical/administrative reasons. The number of protocol steps per unit of time was similar in the two diagnostic groups (n.s. for all protocols). Initial hemodynamic stability (a protocol target) was achieved in 26+/-18 min (mean+/-SD) in cardiac surgery and in 24+/-18 min in septic patients. Sedation targets were reached in 2.4+/-0.2h in cardiac surgery and in 3.6 +/-0.2h in septic patients. Weaning protocol was started in 164 (94%; 154 extubated) cardiac surgery and in 25 (60%; 9 extubated) septic patients. The median (interquartile range) time from starting weaning to extubation (a protocol target) was 89 min (range 44-154 min) for the cardiac surgery patients and 96 min (range 56-205 min) for the septic patients. CONCLUSIONS: Multiple software-driven treatment protocols can be simultaneously applied with high acceptance and rapid achievement of primary treatment goals. Time to reach these primary goals may provide a performance indicator.

Sedation and weaning from mechanical ventilation: effects of process optimization outside a clinical trial.

PURPOSE: We studied the effects of reorganization and changes in the care process, including use of protocols for sedation and weaning from mechanical ventilation, on the use of sedative and analgesic drugs and on length of respiratory support and stay in the intensive care unit (ICU). MATERIALS AND METHODS: Three cohorts of 100 mechanically ventilated ICU patients, admitted in 1999 (baseline), 2000 (implementation I, after a change in ICU organization and in diagnostic and therapeutic approaches), and 2001 (implementation II, after introduction of protocols for weaning from mechanical ventilation and sedation), were studied retrospectively. RESULTS: Simplified Acute Physiology Score II (SAPS II), diagnostic groups, and number of organ failures were similar in all groups. Data are reported as median (interquartile range). Time on mechanical ventilation decreased from 18 (7-41) (baseline) to 12 (7-27) hours (implementation II) (P = .046), an effect which was entirely attributable to noninvasive ventilation, and length of ICU stay decreased in survivors from 37 (21-71) to 25 (19-63) hours (P = .049). The amount of morphine (P = .001) and midazolam (P = .050) decreased, whereas the amount of propofol (P = .052) and fentanyl increased (P = .001). Total Therapeutic Intervention Scoring System-28 (TISS-28) per patient decreased from 137 (99-272) to 113 (87-256) points (P = .009). Intensive care unit mortality was 19% (baseline), 8% (implementation I), and 7% (implementation II) (P = .020). CONCLUSIONS: Changes in organizational and care processes were associated with an altered pattern of sedative and analgesic drug prescription, a decrease in length of (noninvasive) respiratory support and length of stay in survivors, and decreases in resource use as measured by TISS-28 and mortality.

[Value of non-invasive ventilation in intensive care]. / Intérêt de la ventilation non-invasive aux soins intensifs.

Noninvasive ventilation (NIV) refers to the delivery of mechanical ventilation using a nasal or facial mask. Compared to mechanical ventilation with endotracheal intubation, the occurence of complications, mainly infectious, is reduced by NIV. Reduction of respiratory workload and improvement of gas exchange are achieved with the use of NIV. In patients with exacerbations of chronic obstructive pulmonary disease (COPD), NIV reduces the need for endotracheal intubation, the length of ICU stay and the mortality. It is equally effective in acute cardiogenic pulmonary edema and for ventilatory weaning of patients with COPD. In selected groups of patients with acute hypoxemic respiratory failure, NIV diminishes the rate of endotracheal intubation and improves survival. The purpose of this article is to review the mechanisms, the technical aspects and the indications of NIV for the treatment of acute respiratory failure.