ROX index performance to predict high-flow nasal oxygen outcome in Covid-19 related hypoxemic acute respiratory failure.

BACKGROUND: Given the pathophysiology of hypoxemia in patients with Covid-19 acute respiratory failure (ARF), it seemed necessary to evaluate whether ROX index (ratio SpO2/FiO2 to respiratory rate) could accurately predict intubation or death in these patients initially treated by high-flow nasal oxygenation (HFNO). We aimed, therefore, to assess the accuracy of ROX index to discriminate between HFNO failure (sensitivity) and HFNO success (specificity). METHODS: We designed a multicentre retrospective cohort study including consecutive patients with Covid-19 ARF. In addition to its accuracy, we assessed the usefulness of ROX index to predict HFNO failure (intubation or death) via logistic regression. RESULTS: Among 218 ARF patients screened, 99 were first treated with HFNO, including 49 HFNO failures (46 intubations, 3 deaths before intubation). At HFNO initiation (H0), ROX index sensitivity was 63% (95%CI 48-77%) and specificity 76% (95%CI 62-87%) using Youden's index. With 4.88 as ROX index cut-off at H12, sensitivity was 29% (95%CI 14-48%) and specificity 90% (95%CI 78-97%). Youden's index yielded 8.73 as ROX index cut-off at H12, with 87% sensitivity (95%CI 70-96%) and 45% specificity (95%CI 31-60%). ROX index at H0 was associated with HFNO failure (p = 0.0005) in univariate analysis. Multivariate analysis showed that SAPS II (p = 0.0003) and radiographic extension of pulmonary injuries (p = 0.0263), rather than ROX index, were predictive of HFNO failure. CONCLUSIONS: ROX index cut-off values seem population-specific and the ROX index appears to have a technically acceptable but clinically low capability to discriminate between HFNO failures and successes in Covid-19 ARF patients. In addition, SAPS II and pulmonary injuries at ICU admission appear more useful than ROX index to predict the risk of intubation.

Usefulness of video-laryngoscopy with the Airway Scope for intubation performance and learning: an experimental manikin controlled study.

BACKGROUND: Different video-laryngoscopes (VDLs) for endotracheal intubation (ETI) have recently been developed. We compared the performance of the VDL Airway Scope (AWS) with the direct laryngoscopy by Macintosh (DLM) for ETI success, time and learning. METHODS: We performed an experimental manikin controlled study. Twenty experienced (experts) and 40 inexperienced operators (novices) for DLM-ETI were enrolled. None of them had experience with the use of AWS-VDL. Novices were assigned to start learning with DLM or AWS, and two sub-groups of 20 novices were formed. Experts group constituted the control group. Each participant performed 10 ETI attempts with each device on the same standard manikin. The primary endpoint was the ETI success probability. Secondary endpoints were ETI time, technical validity and qualitative evaluation for each technique. We also assessed the learning order and the successive attempts effects for these parameters. RESULTS: Overall, 1200 ETI attempts were performed. ETI success probability was higher with the AWS than with the DLM for all operators (98 vs. 81 %; p < 0.0001) and for experts compared to novices using devices in the same order (97 vs. 83 %; p = 0.0002). Overall ETI time was shorter with the AWS than with the DLM (13 vs. 20 s; p < 0.0001) and for experts compared to novices using devices in the same order (11 vs. 21 s; p < 0.0001). Among novices, those starting learning with AWS had higher ETI success probability (89 vs. 83 %; p = 0.03) and shorter ETI time (18 vs. 21 s; p = 0.02). Technical validity was found better with the AWS than DLM for all operators. Novices expressed global satisfaction and device preference for the AWS, whereas experts were indifferent. CONCLUSIONS: AWS-VDL permits faster, easier and more reliable ETI compared to the DLM whatever the previous airway ETI experience and could be a useful device for DLM-ETI learning.

Early dynamic left intraventricular obstruction is associated with hypovolemia and high mortality in septic shock patients.

INTRODUCTION: Based on previously published case reports demonstrating dynamic left intraventricular obstruction (IVO) triggered by hypovolemia or catecholamines, this study aimed to establish: (1) IVO occurrence in septic shock patients; (2) correlation between the intraventricular gradient and volume status and fluid responsiveness; and (3) mortality rate. METHOD: We prospectively analyzed patients with septic shock admitted to a general ICU over a 28-month period who presented Doppler signs of IVO. Clinical characteristics and hemodynamic parameters as well as echocardiographic data regarding left ventricular function, size, and calculated mass, and left ventricular outflow Doppler pattern and velocity before and after fluid infusions were recorded. RESULTS: During the study period, 218 patients with septic shock were admitted to our ICU. IVO was observed in 47 (22%) patients. Mortality rate at 28 days was found to be higher in patients with than in patients without IVO (55% versus 33%, p < 0.01). Small, hypercontractile left ventricles (end-diastolic left ventricular surface 4.7 ± 2.1 cm(2)/m(2) and ejection fraction 82 ± 12%), and frequent pseudohypertrophy were found in these patients. A rise ≥12% in stroke index was found in 87% of patients with IVO, with a drop of 47% in IVO after fluid infusion. CONCLUSION: Left IVO is a frequent event in septic shock patients with an important correlation with fluid responsiveness. The mortality rate was found to be higher in these patients in comparison with patients without obstruction.

Invasive Geotrichum clavatum fungal infection in an acute myeloid leukaemia patient: a case report and review.

Invasive Geotrichum clavatum fungal infections are extremely rare and unusual, occurring nearly exclusively in patients experiencing prolonged neutropenia during the treatment for acute myeloid leukaemia. Several groups of cases of fatal G. clavatum infection were reported in France between 2011 and 2012, but the ecological niche has not yet been identified. We report a case of a 32-year-old patient with acute myeloid leukaemia who developed G. clavatum sepsis with primary peritonitis, hepatic nodular lesions, and multivisceral failure during aplasia after induction followed by salvage chemotherapy. He was treated with voriconazole and is still alive 1 year after with controlled disease. We then discuss the epidemiological, clinical, and therapeutic features of these serious fungal infections compared to the published data.