Diagnostic, prognostic and clinical value of left ventricular radial strain to identify paradoxical septal motion in ventilated patients with the acute respiratory distress syndrome: an observational prospective multicenter study.

BACKGROUND: Acute cor pulmonale (ACP) is prognostic in patients with acute respiratory distress syndrome (ARDS). Identification of paradoxical septal motion (PSM) using two-dimensional echocardiography is highly subjective. We sought to describe feature-engineered metrics derived from LV radial strain changes related to PSM in ARDS patients with ACP of various severity and to illustrate potential diagnostic and prognostic yield. METHODS: This prospective bicentric study included patients under protective ventilation for ARDS related to COVID-19 who were assessed using transesophageal echocardiography (TEE). Transgastric short-axis view at mid-papillary level was used to visually grade septal motion, using two-dimensional imaging, solely and combined with LV radial strain: normal (grade 0), transient end-systolic septal flattening (grade 1), prolonged end-systolic septal flattening or reversed septal curvature (grade 2). Inter-observer variability was calculated. Feature engineering was performed to calculate the time-to-peak and area under the strain curve in 6 LV segments. In the subset of patients with serial TEE examinations, a multivariate Cox model analysis accounting for new-onset of PSM as a time-dependent variable was used to identify parameters associated with ICU mortality. RESULTS: Overall, 310 TEE examinations performed in 182 patients were analyzed (age: 67 [60-72] years; men: 66%; SAPSII: 35 [29-40]). Two-dimensional assessment identified a grade 1 and grade 2 PSM in 100 (32%) and 48 (15%) examinations, respectively. Inter-rater reliability was weak using two-dimensional imaging alone (kappa = 0.49; 95% CI 0.40-0.58; p < 0.001) and increased with associated LV radial strain (kappa = 0.84, 95% CI 0.79-0.90, p < 0.001). The time-to-peak of mid-septal and mid-lateral segments occurred significantly later in systole and increased with the grade of PSM. Similarly, the area under the strain curve of these segments increased significantly with the grade of PSM, compared with mid-anterior or mid-inferior segments. Severe acute cor pulmonale with a grade 2 PSM was significantly associated with mortality. Requalification in an upper PSM grade using LV radial strain allowed to better identify patients at risk of death (HR: 6.27 [95% CI 2.28-17.2] vs. 2.80 [95% CI 1.11-7.09]). CONCLUSIONS: In objectively depicting PSM and quantitatively assessing its severity, TEE LV radial strain appears as a valuable adjunct to conventional two-dimensional imaging.

Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study.

INTRODUCTION: Acute cor pulmonale (ACP) and patent foramen ovale (PFO) remain common in patients under protective ventilation for acute respiratory distress syndrome (ARDS). We sought to describe the hemodynamic profile associated with either ACP or PFO, or both, during the early course of moderate-to-severe ARDS using echocardiography. METHODS: In this 32-month prospective multicenter study, 195 patients with moderate-to-severe ARDS were assessed using echocardiography during the first 48 h of admission (age: 56 (SD: 15) years; Simplified Acute Physiology Score: 46 (17); PaO2/FiO2: 115 (39); VT: 6.5 (1.7) mL/kg; PEEP: 11 (3) cmH2O; driving pressure: 15 (5) cmH2O). ACP was defined by the association of right ventricular (RV) dilatation and systolic paradoxical ventricular septal motion. PFO was detected during a contrast study using agitated saline in the transesophageal bicaval view. RESULTS: ACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP. Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function. Despite elevated systolic pulmonary artery pressure (sPAP), patients with isolated PFO had a normal RV systolic function. sPAP and PaCO2 levels were significantly correlated. CONCLUSIONS: In patients under protective mechanical ventilation with moderate-to-severe ARDS, ACP was associated with LV restriction and RV failure, whether PFO was present or not. Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.

Right ventricular injury in patients with COVID-19-related ARDS eligible for ECMO support: a multicenter retrospective study.

BACKGROUND: Coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) is associated with high mortality. Extracorporeal membrane oxygenation (ECMO) has been proposed in this setting, but optimal criteria to select target patients remain unknown. Our hypothesis is that evaluation of right ventricular (RV) function could be helpful. The aims of our study were to report the incidence and outcomes of patients eligible for ECMO according to EOLIA criteria, and to identify a subgroup of patients with RV injury, which could be a target for ECMO. METHODS: Retrospective observational study involving 3 French intensive care units (ICUs) of teaching hospitals. Patients with confirmed SARS-CoV-2 infection between March 2020 and March 2021, presenting ARDS and with available echocardiography, were included. Patients were classified in three groups according to whether or not they met the EOLIA criteria and the presence of RV injury (RVI) ("EOLIA -", "EOLIA + RVI -" and "EOLIA + RVI + "). RVI was defined by the association of RV to left ventricular end-diastolic area ratio > 0.8 and paradoxical septal motion. Kaplan-Meier survival curves were used to analyze outcome as well as a Cox model for 90 day mortality. RESULTS: 915 patients were hospitalized for COVID-19, 418 of them with ARDS. A total of 283 patients with available echocardiography were included. Eighteen (6.3%) patients received ECMO. After exclusion of these patients, 107 (40.5%) were classified as EOLIA -, 126 (47.5%) as EOLIA + RVI -, and 32 (12%) as EOLIA + RVI + . Ninety-day mortality was 21% in the EOLIA-group, 44% in the EOLIA + RVI-group, and 66% in the EOLIA + RVI + group (p < 0.001). After adjustment, RVI was statistically associated with 90-day mortality (HR = 1.92 [1.10-3.37]). CONCLUSIONS: Among COVID-19-associated ARDS patients who met the EOLIA criteria, those with significant RV pressure overload had a particularly poor outcome. This subgroup may be a more specific target for ECMO. This represented 12% of our cohort compared to 60% of patients who met the EOLIA criteria only. How the identification of this high-risk subset of patients translates into patient-centered outcomes remains to be evaluated.

Feasibility of right ventricular longitudinal systolic function evaluation with transthoracic echocardiographic indices derived from tricuspid annular motion: a preliminary study in acute respiratory distress syndrome.

INTRODUCTION: Assessment of right ventricular (RV) function in patients with acute respiratory distress syndrome (ARDS) remains challenging. Transthoracic echocardiographic (TTE) indices based on longitudinal systolic RV function are now considered as a reliable evaluation of RV function. We investigated feasibility of two methods in ARDS patients. METHODS: Prospective observational study. TTE was performed after 12-36 hours of mechanical ventilation. Feasibility of tricuspid annular motion (S(t) ), tricuspid annular plane systolic excursion (TAPSE) was compared to usual two-dimensional (2D) study: fractional area change (RV(FAC) ) and ratio of right to left ventricular end-diastolic area (RVEDA/LVEDA). RESULTS: Fifty patients were investigated, with TTE possible in all but two patients. Feasibility was 62% for RV(FAC), 72% for RVEDA/LVEDA, and 96% for TAPSE and S(t). RV dilatation (RVEDA/LVEDA ≥ 0.60) was found in 16 patients, including 4 patients with acute cor pulmonale. A longitudinal RV dysfunction (TAPSE < 12 mm or S(t) < 11.5 cm/sec) was suspected in 30% of patients. Relation between both longitudinal indices was modest (r(2) = 0.36, P < 0.001). TAPSE (but not S(t) ) was found poorly related to RV(FAC) (r(2) = 0.27, P = 0.03). Both indices were related to LV function (S(t) : r(2) = 0.27, TAPSE: r(2) = 0.17, both P < 0.05). CONCLUSION: Despite a superior feasibility than 2D study, our results suggest that both indices may not bring identical information to echo study. TAPSE may be more adapted to ICU use than S(t) . Both should be further investigated in terms of analysis of RV function and ventricular interdependence. Their relations with LV function may limit their use as sole markers of RV function in this population.

Respiratory pulse pressure variation fails to predict fluid responsiveness in acute respiratory distress syndrome.

INTRODUCTION: Fluid responsiveness prediction is of utmost interest during acute respiratory distress syndrome (ARDS), but the performance of respiratory pulse pressure variation (ΔRESPPP) has scarcely been reported. In patients with ARDS, the pathophysiology of ΔRESPPP may differ from that of healthy lungs because of low tidal volume (Vt), high respiratory rate, decreased lung and sometimes chest wall compliance, which increase alveolar and/or pleural pressure. We aimed to assess ΔRESPPP in a large ARDS population. METHODS: Our study population of nonarrhythmic ARDS patients without inspiratory effort were considered responders if their cardiac output increased by >10% after 500-ml volume expansion. RESULTS: Among the 65 included patients (26 responders), the area under the receiver-operating curve (AUC) for ΔRESPPP was 0.75 (95% confidence interval (CI95): 0.62 to 0.85), and a best cutoff of 5% yielded positive and negative likelihood ratios of 4.8 (CI95: 3.6 to 6.2) and 0.32 (CI95: 0.1 to 0.8), respectively. Adjusting ΔRESPPP for Vt, airway driving pressure or respiratory variations in pulmonary artery occlusion pressure (ΔPAOP), a surrogate for pleural pressure variations, in 33 Swan-Ganz catheter carriers did not markedly improve its predictive performance. In patients with ΔPAOP above its median value (4 mmHg), AUC for ΔRESPPP was 1 (CI95: 0.73 to 1) as compared with 0.79 (CI95: 0.52 to 0.94) otherwise (P = 0.07). A 300-ml volume expansion induced a ≥ 2 mmHg increase of central venous pressure, suggesting a change in cardiac preload, in 40 patients, but none of the 28 of 40 nonresponders responded to an additional 200-ml volume expansion. CONCLUSIONS: During protective mechanical ventilation for early ARDS, partly because of insufficient changes in pleural pressure, ΔRESPPP performance was poor. Careful fluid challenges may be a safe alternative.

Risk factors and outcomes of early acute kidney injury in infective endocarditis: A retrospective cohort study.

OBJECTIVES: The incidence of acute kidney injury (AKI) in infective endocarditis (IE), its risk factors and consequences on patient and renal survival remain debated. METHODS: Patients hospitalized for a first episode of IE (possible or definite according to modified Duke criteria) between 2013 and 2016 were included. The primary endpoint was to determine risk factors for early AKI (E-AKI) during the first week of management of IE. RESULTS: A total of 276 patients were included: 220 (79.7%) had definite IE and 56 (20.3%) had possible IE. E-AKI occurred in 150 patients (53%). IE due to Staphylococcus aureus (OR 3.41; 95% CI 1.83-6.39; p<0.01), history of diabetes (OR 2.34; 95% CI 1.25-4.37; p<0.01), peripheral arterial disease (OR 2.59; 95% CI 1.07-6.23; p<0.05), immunological manifestations (OR 3.11; 95% CI 1.31-7.39; p=0.01), and use of norepinephrine (OR 3.44; 95% CI 1.72-7.02; p<0.01) were associated with E-AKI. In subgroup analysis, infectious disease consultation was associated with a lower risk of AKI at day 7 (OR 0.41; 95% CI 0.16-0.88; p=0.04). E-AKI was associated with 1-year mortality (OR 1.65; 95% CI 1.03-2.64; p=0.04) and chronic kidney disease progression (OR 2.23; 95% CI 1.30-3.82; p<0.01). CONCLUSIONS: E-AKI is common in IE and often associated with non-modifiable variables. Multidisciplinary management should be mandatory, and awareness of AKI diagnosis and etiological explorations should be raised.

A multicentre case-control study of nonsteroidal anti-inflammatory drugs as a risk factor for severe sepsis and septic shock.

INTRODUCTION: We aimed to establish whether the use of nonsteroidal anti-inflammatory drugs (NSAIDs) during evolving bacterial community-acquired infection in adults is associated with severe sepsis or septic shock. METHODS: We conducted a multicentre case-control study in eight intensive care units. Cases were all adult patients admitted for severe sepsis or septic shock due to a bacterial community-acquired infection. Control individuals were patients hospitalized with a mild community-acquired infection. Each case was matched to one control for age, presence of diabetes and site of infection. RESULTS: The main outcome measures were the proportions of cases and controls exposed to NSAIDs or aspirin during the period of observation. In all, 152 matched pairs were analyzed. The use of NSAIDs or aspirin during the observation period did not differ between cases and controls (27% versus 28; odds ratio = 0.93, 95% confidence interval [CI] = 0.52 to 1.64). If aspirin was not considered or if a distinction was made between acute and chronic drug treatment, there remained no difference between groups. However, the median time to prescription of effective antibiotic therapy was longer for NSAID users (6 days, 95% CI = 3 to 7 days) than for nonusers (3 days, 95% CI = 2 to 3 days; P = 0.02). CONCLUSIONS: In this study, the use of NSAIDs or aspirin during evolving bacterial infection was frequent and occurred in one-quarter of the patients with such infection. Although the use of NSAIDs by patients with severe sepsis or septic shock did not differ from their use by those with mild infection at the same infected site, we observed a longer median time to prescription of effective antibiotic therapy in NSAID users.

Tracking hypotension and dynamic changes in arterial blood pressure with brachial cuff measurements.

BACKGROUND: Arterial cannulation is strongly recommended during shock. Nevertheless, this procedure is associated with significant risks and may delay other emergent procedures. We assessed the discriminative power of brachial cuff oscillometric noninvasive blood pressure (NIBP) for identifying patients with an invasive mean arterial blood pressure (MAP) below 65 mm Hg or increasing their invasive MAP after cardiovascular interventions. METHODS: This prospective study, conducted in three intensive care units, included adults in circulatory failure who underwent 45 degrees passive leg raising, 300 mL fluid loading, and additional 200 mL fluid loading. The collected data were four invasive and noninvasive MAP measurements at each study phase. RESULTS: Among 111 patients (50 septic, 15 cardiogenic, and 46 other source of shock), when averaging measurements of each study phase, NIBP measurements accurately predicted an invasive MAP lower than 65 mm Hg: area under the receiver operating characteristic curve 0.90 (95% CI: 0.71-1), positive and negative likelihood ratios 7.7 (95% CI: 5.4-11) and 0.31 (95% CI: 0.22-0.44) (cutoff 65 mm Hg). For identifying patients increasing their invasive MAP by more than 10%, the area under the receiver operating characteristic curve was 0.95 (95% CI: 0.92-0.96); positive and negative likelihood ratios (cutoff 10%) were 25.7 (95% CI: 10.8-61.4) and 0.26 (95% CI: 0.2-0.34). CONCLUSIONS: NIBP measurements have a good discriminative power for identifying hypotensive patients and performed even better in tracking MAP changes, provided that one averages four NIBP measurements.

Diagnostic performance of multiplex PCR on pulmonary samples versus nasopharyngeal aspirates in community-acquired severe lower respiratory tract infections.

BACKGROUND: PCR-based techniques for the diagnosis of community- acquired severe lower respiratory tract infections are becoming the standard of care. However, their relative ability to identify either atypical bacteria or viruses that cause LRTI from clinical samples from various sources is yet to be determined. OBJECTIVES AND STUDY DESIGN: The aim of our study was to compare the diagnostic yield of nasopharyngeal aspirates with that of pulmonary samples for the etiological diagnosis of severe acute lower respiratory tract infections by multiplex PCR. Patients were adults with community-acquired pneumonia or acute exacerbation of chronic obstructive pulmonary disease. RESULTS: We obtained concordant results for 81 (79%) of the 103 pairs of samples. In 14 of the 22 discordant results, more pathogens were evidenced in the lower respiratory tract samples. CONCLUSIONS: Pulmonary samples had a similar diagnostic sensitivity for virus detection by multiplex PCR as nasopharyngeal aspirates. In contrast, in our study, the diagnostic efficacy of pulmonary samples for Legionella pneumophila over simple aspirates was clearly superior.

Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction.

BACKGROUND: Vasopressor agents could have certain specific effects in patients with cardiogenic shock (CS) after myocardial infarction, which may influence outcome. Although norepinephrine and epinephrine are currently the most commonly used agents, no randomized trial has compared their effects, and intervention data are lacking. OBJECTIVES: The goal of this paper was to compare in a prospective, double-blind, multicenter, randomized study, the efficacy and safety of epinephrine and norepinephrine in patients with CS after acute myocardial infarction. METHODS: The primary efficacy outcome was cardiac index evolution, and the primary safety outcome was the occurrence of refractory CS. Refractory CS was defined as CS with sustained hypotension, end-organ hypoperfusion and hyperlactatemia, and high inotrope and vasopressor doses. RESULTS: Fifty-seven patients were randomized into 2 study arms, epinephrine and norepinephrine. For the primary efficacy endpoint, cardiac index evolution was similar between the 2 groups (p = 0.43) from baseline (H0) to H72. For the main safety endpoint, the observed higher incidence of refractory shock in the epinephrine group (10 of 27 [37%] vs. norepinephrine 2 of 30 [7%]; p = 0.008) led to early termination of the study. Heart rate increased significantly with epinephrine from H2 to H24 while remaining unchanged with norepinephrine (p < 0.0001). Several metabolic changes were unfavorable to epinephrine compared with norepinephrine, including an increase in cardiac double product (p = 0.0002) and lactic acidosis from H2 to H24 (p < 0.0001). CONCLUSIONS: In patients with CS secondary to acute myocardial infarction, the use of epinephrine compared with norepinephrine was associated with similar effects on arterial pressure and cardiac index and a higher incidence of refractory shock. (Study Comparing the Efficacy and Tolerability of Epinephrine and Norepinephrine in Cardiogenic Shock [OptimaCC]; NCT01367743).

[Acute respiratory failure and septic shock induced by Mycobacterium bovis. A rare side effect of intravesical BCG therapy]. / Atteinte respiratoire sévère et choc septique à Mycobacterium bovis. Une complication rare de la BCG thérapie intravésicale.

INTRODUCTION: Intravesical bacillus Calmette-Guerin (BCG) therapy, recommended for superficial bladder tumors, triggers side effects in fewer than 5% of patients. The most severe side effects, however, are septic shock and acute respiratory failure. CASE: A 70-year-old man was hospitalized for septic shock with acute respiratory and renal failure after intravesical instillation of BCG, which was identified in the gastric aspiration sample. Treatment with rifampicin, ethambutol, isoniazid, and corticosteroid therapy, as well as standard reanimation measures, led to the patient's recovery. DISCUSSION: This case shows the potentially severe side effects of intravesical BCG instillation. Although this treatment is well tolerated in more than 95% of patients and its systemic complications can be effectively treated, these side effects can be life-threatening.

Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact.

RATIONALE: Increased right ventricle (RV) afterload during acute respiratory distress syndrome (ARDS) may induce acute cor pulmonale (ACP). OBJECTIVES: To determine the prevalence and prognosis of ACP and build a clinical risk score for the early detection of ACP. METHODS: This was a prospective study in which 752 patients with moderate-to-severe ARDS receiving protective ventilation were assessed using transesophageal echocardiography in 11 intensive care units. The study cohort was randomly split in a derivation (n = 502) and a validation (n = 250) cohort. MEASUREMENTS AND MAIN RESULTS: ACP was defined as septal dyskinesia with a dilated RV [end-diastolic RV/left ventricle (LV) area ratio >0.6 (≥1 for severe dilatation)]. ACP was found in 164 of the 752 patients (prevalence of 22 %; 95 % confidence interval 19-25 %). In the derivation cohort, the ACP risk score included four variables [pneumonia as a cause of ARDS, driving pressure ≥18 cm H2O, arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio <150 mmHg, and arterial carbon dioxide partial pressure ≥48 mmHg]. The ACP risk score had a reasonable discrimination and a good calibration. Hospital mortality did not differ between patients with or without ACP, but it was significantly higher in patients with severe ACP than in the other patients [31/54 (57 %) vs. 291/698 (42 %); p = 0.03]. Independent risk factors for hospital mortality included severe ACP along with male gender, age, SAPS II, shock, PaO2/FiO2 ratio, respiratory rate, and driving pressure, while prone position was protective. CONCLUSIONS: We report a 22 % prevalence of ACP and a poor outcome of severe ACP. We propose a simple clinical risk score for early identification of ACP that could trigger specific therapeutic strategies to reduce RV afterload.

Preanalytical conditions of point-of-care testing in the intensive care unit are decisive for analysis reliability.

BACKGROUND: Point-of-care testing (POCT) systems enable a wide range of tests to be rapidly performed at the bedside and have attracted increasing interest in the intensive care unit (ICU). However, previous studies comparing the concordance of POCT with central laboratory testing have reported divergent findings. Most reported studies on POCT reliability have focused on analyzer performance rather than the preanalytical phase. The aim of this study was to assess the reliability of results provided by point-of-care analyzers according to the organization of the care units and the preanalytical process. METHODS: In three adult critical care units, 491 paired blood samples were analyzed for hemoglobin, potassium, and sodium concentrations by blood gas analyzers (identical reference) and the central laboratory. The clinical significance of agreement was assessed using Bland-Altman plots. A quality improvement program was then implemented to improve the preanalytical POCT process for one ICU where there was poor agreement. A second comparison was performed on 278 paired blood samples in this unit. RESULTS: Biases were clinically nonsignificant for potassium and sodium concentrations for all tested critical care units, relative to the reference method. However, biases [limits of agreements] for hemoglobin analyses were clearly affected by the preanalytical process: -3 [-6; 1] g/L in the operating room, -5 [-28; 17] g/L in a 10-bed ICU, and -19 [-64; 27] g/L in a 37-bed ICU. The quality approach was implemented in the 37-bed ICU and led to corrective actions that: (1) reduced the time for the POCT preanalytical phase; (2) implemented a checklist to validate the preanalytical conditions; (3) used technical innovations. The improvement of the preanalytical process resulted in a substantial decrease of the bias for hemoglobin concentration measurements: -3 [-10; 5] g/L in the 37-bed ICU. CONCLUSION: We clearly demonstrate that an identical analyzer can provide results of varying quality depending on the local constraints of the ICUs. We demonstrate that quality management focused on the preanalytical process and performed by the partners involved in the POCT can overcome these issues.

Cerebral aspergillosis in the critically ill: two cases of successful medical treatment.

OBJECTIVE: Invasive aspergillosis is associated with a poor prognosis, especially in critically ill patients with cerebral involvement. We present two cases of cerebral invasive aspergillosis successfully treated in the intensive care unit with combination antifungal therapies and without surgery. CASE PRESENTATION: The first patient was a 49-year-old man with rheumatoid arthritis who received corticosteroid and cyclophosphamide treatment and developed pulmonary and cerebral invasive aspergillosis. After failure of voriconazole the patient had a successful outcome with voriconazole and liposomal amphotericin B therapy. The patient returned home after an 8-month hospital stay. The second patient was a 54-year-old woman with pulmonary neoplasia and corticosteroid treatment who developed pulmonary and cerebral invasive aspergillosis. After failure of voriconazole and liposomal amphotericin B therapy the patient had a favorable outcome with liposomal amphotericin B and caspofungin therapy. The patient died 10 months after initial diagnosis of cardiac tamponade unrelated to fungal infection. DISCUSSIONS: These cases illustrate the improving prognosis of invasive aspergillosis due to the availability of new treatments, especially in cases of cerebral involvement. It also demonstrates that the outcome of critically ill patients requiring mechanical ventilation for invasive aspergillosis can be favorable. The treatment of patients with invasive cerebral aspergillosis in the intensive care setting should be encouraged.

Clinical and economic outcomes of infective endocarditis.

BACKGROUND: In France, the estimated annual incidence of infective endocarditis (IE) is 33.8 cases per million residents. Valvular surgery is frequently undergone. We report an epidemiological and economic study of IE for 2007-2009 in a French region, using the hospital discharge database (HDD). METHODS: The population studied concerned all the patients living in Centre region, France, hospitalized for IE. We extracted hospital stay data for IE from the regional HDD, with a definition based on IE-related diagnosis codes. The predictive positive value (PPV) and sensitivity (Se) of the definition were 87.4% and 90%, respectively, according to the Duke criteria (definite IE frequency 74.4%). Hospitalization costs were estimated, taking into account the fixed hospital charges of the diagnosis-related group (DRG) and supplementary charges due to intensive care unit (ICU) stay. RESULTS: The analysis included 578 patients. The annual average incidence was 45.4 cases per million residents. Valvular surgery was performed in 19.4% of cases. The hospital mortality was 17.6%. Multivariate analysis identified as risk factors for mortality an age ≥ 70 years (odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.78-5.18), staphylococcal IE (OR = 3.3, 95% CI = 1.9-5.7), chronic renal insufficiency (OR = 2.04, 95% CI = 1.00-4.15), ischemic stroke (OR = 2.55, 95% CI = 1.19-5.47), and hemorrhagic stroke (OR = 5.7, 95% CI = 1.9-17.3). The average cost per episode was $20 103 (€15 281). CONCLUSIONS: We report a higher incidence of IE than described by the French national study of 2008. Valvular surgery was considerably less frequent than in the published data, whereas mortality was similar. IE generates substantial costs.

Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study.

PURPOSE: We sought to determine the prevalence of and factors associated with acute cor pulmonale (ACP) and patent foramen ovale (PFO) at the early phase of acute respiratory distress syndrome (ARDS), and to assess their relation with mortality. METHODS: In this prospective multicenter study, 200 patients submitted to protective ventilation for early moderate to severe ARDS [PaO2/F(I)O2: 115 ± 39 with F(I)O2: 1; positive end-expiratory pressure (PEEP): 10.6 ± 3.1 cmH2O] underwent transthoracic (TTE) and transesophageal echocardiography (TEE) <48 h after admission. Echocardiograms were independently interpreted by two experts. Factors associated with ACP, PFO, and 28-day mortality were identified using multivariate regression analysis. RESULTS: TEE depicted ACP in 45/200 patients [22.5%; 95% confidence interval (CI) 16.9-28.9%], PFO in 31 patients (15.5%; 95% CI 10.8-21.3%), and both ACP and PFO in 9 patients (4.5%; 95% CI 2.1-8.4%). PFO shunting was small and intermittent in 27 patients, moderate and consistent in 4 patients, and large or extensive in no instances. PaCO2 >60 mmHg was strongly associated with ACP [odds ratio (OR) 3.70; 95% CI 1.32-10.38; p = 0.01]. No factor was independently associated with PFO, with only a trend for age (OR 2.07; 95% CI 0.91-4.72; p = 0.08). Twenty-eight-day mortality was 23%. Plateau pressure (OR 1.15; 95% CI 1.05-1.26; p < 0.01) and air leaks (OR 5.48; 95% CI 1.30-22.99; p = 0.02), but neither ACP nor PFO, were independently associated with outcome. CONCLUSIONS: TEE screening allowed identification of ACP in one-fourth of patients submitted to protective ventilation for early moderate to severe ARDS. PFO shunting was less frequent and never large or extensive. ACP and PFO were not related to outcome.

Randomized comparison of 2 protocols to prevent acquisition of methicillin-resistant Staphylococcus aureus: results of a 2-center study involving 500 patients.

OBJECTIVE: To compare an interventional protocol with a standard protocol for preventing the acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in the intensive care unit (ICU). DESIGN: Prospective, randomized, controlled, parallel-group, nonblinded clinical trial. SETTING: Medical ICUs of 2 French university hospitals. PARTICIPANTS: Five hundred adults with an expected length of stay in the ICU greater than 48 hours. INTERVENTIONS: For the intervention group, the protocol required repeated MRSA screening, contact and droplet isolation precautions for patients at risk for MRSA at ICU admission and for MRSA-positive patients, and decontamination with nasal mupirocin and chlorhexidine body wash for MRSA-positive patients. For the standard group, the standard precautions protocol was used, and the results of repeated MRSA screening in the standard group were not communicated to investigators. MAIN OUTCOME MEASURE: MRSA acquisition rate in the ICU. An audit was conducted to assess compliance with hygiene and isolation precautions. RESULTS: In the intent-to-treat analysis ([Formula: see text]), the MRSA acquisition rate in the ICU was similar in the standard (13 [5.3%] of 243) and intervention (16 [6.5%] of 245) groups ([Formula: see text]). The audit showed that the overall compliance rate was 85.5% in the standard group and 84.1% in the intervention group ([Formula: see text]), although compliance was higher when isolation precautions were absent than when they were in place (88.2% vs 79.1%; [Formula: see text]). MRSA incidence rates were higher without isolation precautions (7.57‰) than with isolation precautions (2.36‰; [Formula: see text]). CONCLUSIONS: Individual allocation to MRSA screening, isolation precautions, and decontamination do not provide individual benefit in reducing MRSA acquisition, compared with standard precautions, although the collective risk was lower during the periods of isolation. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00151606.

Central venous pressure measurements improve the accuracy of leg raising-induced change in pulse pressure to predict fluid responsiveness.

PURPOSE: Passive leg raising (PLR) is a maneuver performed to test the cardiac Frank-Starling mechanism. We assessed the influence of PLR-induced changes in preload on the performance of PLR-induced change in pulse pressure (Delta(PLR)PP) and cardiac output (Delta(PLR)CO) for fluid responsiveness prediction. METHODS: Sedated, nonarrhythmic patients with persistent shock were included in this prospective multicenter study. Cardiac output and pulse pressure were measured at baseline (patient supine), during PLR (lower limbs lifted to 45 degrees) and after 500-ml volume expansion. Patients were classified as responders or not. RESULTS: In the whole population (n = 102), the area under the receiver-operating characteristic curve (AUC) was 0.76 for Delta(PLR)PP and was higher for Delta(PLR)CO (0.89)(p < 0.05), but likelihood ratios were close to 1. In patients with a PLR-induced increase in central venous pressure (CVP) of at least 2 mmHg (n = 49), Delta(PLR)PP and Delta(PLR)CO disclosed higher AUCs than in the rest of the population (0.91 vs. 0.66 and 0.98 vs. 0.83; p < 0.05); positive/negative likelihood ratios were 9.3/0.14 (8% cutoff level) and 30/0.07 (7% cutoff level), respectively. CONCLUSIONS: A PLR-induced change in CVP > or =2 mmHg was required to allow clinical usefulness of PLR-derived indices. In this situation, Delta(PLR)PP performed well for predicting fluid responsiveness in deeply sedated patients.