Oxygen therapy and noninvasive respiratory supports in acute hypoxemic respiratory failure: a narrative review.

BACKGROUND: This narrative review was written by an expert panel to the members of the jury to help in the development of clinical practice guidelines on oxygen therapy. RESULTS: According to the expert panel, acute hypoxemic respiratory failure was defined as PaO2 < 60 mm Hg or SpO2 < 90% on room air, or PaO2/FiO2 ≤ 300 mm Hg. Supplemental oxygen should be administered according to the monitoring of SpO2, with the aim at maintaining SpO2 above 92% and below 98%. Noninvasive respiratory supports are generally reserved for the most hypoxemic patients with the aim of relieving dyspnea. High-flow nasal cannula oxygen (HFNC) seems superior to conventional oxygen therapy (COT) as a means of avoiding intubation and may therefore be should probably be used as a first-line noninvasive respiratory support in patients requiring more than 6 L/min of oxygen or PaO2/FiO2 ≤ 200 mm Hg and a respiratory rate above 25 breaths/minute or clinical signs of respiratory distress, but with no benefits on mortality. Continuous positive airway pressure (CPAP) cannot currently be recommended as a first-line noninvasive respiratory support, since its beneficial effects on intubation remain uncertain. Despite older studies favoring noninvasive ventilation (NIV) over COT, recent clinical trials fail to show beneficial effects with NIV compared to HFNC. Therefore, there is no evidence to support the use of NIV or CPAP as first-line treatment if HFNC is available. Clinical trials do not support the hypothesis that noninvasive respiratory supports may lead to late intubation. The potential benefits of awake prone positioning on the risk of intubation in patients with COVID-19 cannot be extrapolated to patients with another etiology. CONCLUSIONS: Whereas oxygen supplementation should be initiated for patients with acute hypoxemic respiratory failure defined as PaO2 below 60 mm Hg or SpO2 < 90% on room air, HFNC should be the first-line noninvasive respiratory support in patients with PaO2/FiO2 ≤ 200 mm Hg with increased respiratory rate. Further studies are needed to assess the potential benefits of CPAP, NIV through a helmet and awake prone position in patients with acute hypoxemic respiratory failure not related to COVID-19.

Outcomes of Severe ARDS COVID-19 Patients Denied for Venovenous ECMO Support: A Prospective Observational Comparative Study.

Background: Few data are available concerning the outcome of patients denied venovenous extracorporeal membrane oxygenation (VV-ECMO) relative to severe acute respiratory distress syndrome (ARDS) due to COVID-19. Methods: We compared the 90-day survival rate of consecutive adult patients for whom our center was contacted to discuss VV-ECMO indication. Three groups of patients were created: patients for whom VV-ECMO was immediately indicated (ECMO-indicated group), patients for whom VV-ECMO was not indicated at the time of the call (ECMO-not-indicated group), and patients for whom ECMO was definitely contraindicated (ECMO-contraindicated group). Results: In total, 104 patients were referred for VV-ECMO support due to severe COVID-19 ARDS. Among them, 32 patients had immediate VV-ECMO implantation, 28 patients had no VV-ECMO indication, but 1 was assisted thereafter, and 44 patients were denied VV-ECMO for contraindication. Among the 44 patients denied, 30 were denied for advanced age, 24 for excessive prior duration of mechanical ventilation, and 16 for SOFA score >8. The 90-day survival rate was similar for the ECMO-indicated group and the ECMO-not-indicated group at 62.1 and 61.9%, respectively, whereas it was significantly lower (20.5%) for the ECMO-contraindicated group. Conclusions: Despite a low survival rate, 50% of patients were at home 3 months after being denied for VV-ECMO for severe ARDS due to COVID-19.

Microvesicles Are Associated with Early Veno Venous ECMO Circuit Change during Severe ARDS: A Prospective Observational Pilot Study.

BACKGROUND: Veno venous Extra Corporeal Membrane Oxygenation (vvECMO) is associated with frequent hematological ECMO-related complications needing ECMO circuit change. Microvesicles (MVs) interplay during the thrombosis-fibrinolysis process. The main objective of the study was to identify subpopulations of MVs associated with indications of early vvECMO circuit change. METHODS: This is a prospective observational monocenter cohort study. Blood gas was sampled on the ECMO circuit after the membrane oxygenator to measure the PO2 post oxy at inclusion, day 3, day 7 and the day of ECMO circuit removal. Blood samples for MV analysis were collected at inclusion, day 3, day 7 and the day of ECMO circuit removal. MV subpopulations were identified by flow cytometry. RESULTS: Nineteen patients were investigated. Seven patients (37%) needed an ECMO circuit change for hemolysis (n = 4), a pump thrombosis with fibrinolysis (n = 1), persistent thrombocytopenia with bleeding (n = 1) and a decrease of O2 transfer (n = 1). Levels of leukocyte and endothelial MVs were significantly higher at inclusion for patients who thereafter had an ECMO circuit change (p = 0.01 and p = 0.001). The areas under the received operating characteristics curves for LeuMVs and EndoMVs sampled the day of cannulation and the need for ECMO circuit change were 0.84 and 0.92, respectively. PO2 post oxy did not significantly change except for in one patient during the ECMO run. CONCLUSIONS: Our pilot study supports the potential interest of subpopulations of microvesicles early associated with hematological ECMO-related complications. Our results warrant further studies.

COVID-19 among undocumented migrants admitted to French intensive care units during the 2020-2021 period: a retrospective nationwide study.

BACKGROUND: Before the Coronavirus Disease 2019 (COVID-19) pandemic in France, undocumented migrants had a higher risk than general population for being admitted to the intensive care unit (ICU) because of acute respiratory failure or severe infection. Specific data concerning the impact of COVID-19 on undocumented migrants in France are lacking. We aimed to analyze the mortality and respiratory severity of COVID-19 in this specific population. We retrospectively included all undocumented adult migrants admitted in French ICUs from March 2020 through April 2021 using the French nationwide hospital information system (Programme de Médicalisation des Systèmes d'Information). We focused on admissions related to COVID-19. Undocumented migrants were compared to the general population, first in crude analysis, then after matching on age, severity and main comorbidities. The primary outcome was the ICU mortality from COVID-19. Secondary objectives were the incidence of acute respiratory distress syndrome (ARDS), the need for mechanical ventilation (MV), the duration of MV, ICU and hospital stay. RESULTS: During the study period, the rate of ICU admission among patients hospitalized for COVID-19 was higher for undocumented migrants than for general population (463/1627 (28.5%) vs. 81 813/344 001 (23.8%); p < 0.001). Although ICU mortality was comparable after matching (14.3% for general population vs. 13.3% for undocumented migrants; p = 0.50), the incidence of ARDS was higher among undocumented migrants (odds ratio, confidence interval (OR (CI)) 1.25 (1.06-1.48); p = 0.01). Undocumented migrants needed more frequently invasive MV (OR (CI) 1.2 (1.01-1.42); p = 0.04 than general population. There were no differences between groups concerning duration of MV, ICU and hospital length of stay. CONCLUSION: During the first waves of COVID-19 in France, undocumented migrants had a mortality similar to the general population but a higher risk for ICU admission and for developing an ARDS. These results highlight the need for reinforcing prevention and improving primary healthcare access for people in irregular situation.

Effects of ambient air pollutants on ARDS incidence and outcome: a narrative review.

BACKGROUND: Exposure to air pollutants promotes inflammation, cancer, and mortality in chronic diseases. Acute respiratory distress syndrome (ARDS) is a common condition among intensive care unit patients and is associated with a high mortality rate. ARDS is characterized by significant lung inflammation, which can be replicated in animal models by acute exposure to high doses of various air pollutants. Recently, several clinical studies have been conducted in different countries to investigate the role of chronic or acute air pollutant exposure in enhancing both ARDS incidence and severity. RESULTS: Chronic exposure studies have mainly been conducted in the US and France. The results of these studies suggest that some air pollutants, notably ozone, nitrogen dioxide, and particulate matter, increase susceptibility to ARDS and associated mortality. Furthermore, their impact may differ according to the cause of ARDS. A cohort study conducted in an urbanized zone in China showed that exposure to very high levels of air pollutants in the few days preceding intensive care unit admission was associated with an increased incidence of ARDS. The effects of acute exposure are more debatable regarding ARDS incidence and severity. CONCLUSION: There is a likely relationship between air pollutant exposure and ARDS incidence and severity. However, further studies are required to determine which pollutants are the most involved and which patients are the most affected. Due to the prevalence of ARDS, air pollutant exposure may have a significant impact and could be a key public health issue.

[Tagravpa: Help table and grid for identifying the risk of aggravation and early rehospitalization of elderly persons 75 years and older referred to emergency departments and/or hospitalized in care units]. / Tagravpa : Tableau d'aide et grille de repérage du risque d'aggravation et de réhospitalisation précoce des personnes âgées de 75 ans et plus adressées aux urgences et/ou hospitalisées dans les unités de soins.

People aged 75 and over, frail or dependent are the most frequently hospitalized, particularly via the emergency department, and are sometimes readmitted to hospital less than a month after their discharge. Article 70 of the 2012 social security financing act has set up experiments aimed at improving the care pathway for the elderly. In this context, Marseille University Hospital has developed a table of help and grid for identifying the risk of aggravation of the elderly (Tagravpa). Comprising nine medical-psycho-social items, the grid enables the identification of the risk of aggravation to which is associated a score for identifying the risk of early re-hospitalization for the modeling of care pathways. A study was conducted in two departments. In cardiology for readmission at 1 month the results showed a grid positivity threshold of 6 for sensitivity measured at 56,6% (95% CI: 22,7-84,7) and specificity of 61,5% (95% CI: 40,7-79,1). In Emergency Department the results showed a positivity threshold of 4 for sensitivity at 83,3% (95% CI: 57,7-95,6) and specificity at 45,5% (95% CI: 36,8-54,3). This grid, called TAGRAVPA appears as a simple tool for identifying the risk of early re-hospitalization. It is applicable in a hospital environment, whatever the department and allows the initiation of an adapted path for the elderly person hospitalized or returning home from the emergency department.

Response to Prone Position in COVID-19 and Non-COVID-19 Patients with Severe ARDS Supported by vvECMO.

BACKGROUND: For moderate to severe acute respiratory distress syndrome (ARDS), lung-protective ventilation combined with prolonged and repeated prone position (PP) is recommended. For the most severe patients for whom this strategy failed, venovenous extracorporeal membrane oxygenation (vv-ECMO) allows a reduction in ventilation-induced lung injury and improves survival. Some aggregated data have suggested a benefit regarding survival in pursuing PP during vv-ECMO. The combination of PP and vv-ECMO has been also documented in COVID-19 studies, although there is scarce evidence concerning respiratory mechanics and gas exchange response. The main objective was to compare the physiological response of the first PP during vv-ECMO in two cohorts of patients (COVID-19-related ARDS and non-COVID-19 ARDS) regarding respiratory system compliance (CRS) and oxygenation changes. METHODS: This was a single-center, retrospective, and ambispective cohort study in the ECMO center of Marseille, France. ECMO was indicated according to the EOLIA trial criteria. RESULTS: A total of 85 patients were included, 60 in the non-COVID-19 ARDS group and 25 in the COVID-19-related ARDS group. Lung injuries of the COVID-19 cohort exhibited significantly higher severity with a lower CRS at baseline. Concerning the main objective, the first PP during vv-ECMO was not associated with a change in CRS or other variation in respiratory mechanic variables in both cohorts. By contrast, oxygenation was improved only in the non-COVID-19 ARDS group after a return to the supine position. Mean arterial pressure was higher during PP as compared with a return to the supine position in the COVID-19 group. CONCLUSION: We found distinct physiological responses to the first PP in vv-ECMO-supported ARDS patients according to the COVID-19 etiology. This could be due to higher severity at baseline or specificity of the disease. Further investigations are warranted.

Awake prone position in COVID-19 acute respiratory failure: a randomised crossover study using electrical impedance tomography.

Background: The goal of this study was to determine whether an awake prone position (aPP) reduces the global inhomogeneity (GI) index of ventilation measured by electrical impedance tomography (EIT) in COVID-19 patients with acute respiratory failure (ARF). Methods: This prospective crossover study included COVID-19 patients with COVID-19 and ARF defined by arterial oxygen tension:inspiratory oxygen fraction (P aO2 :F IO2 ) of 100-300 mmHg. After baseline evaluation and 30-min EIT recording in the supine position (SP), patients were randomised into one of two sequences: SP-aPP or aPP-SP. At the end of each 2-h step, oxygenation, respiratory rate, Borg scale and 30-min EIT were recorded. Results: 10 patients were randomised in each group. The GI index did not change in the SP-aPP group (baseline 74±20%, end of SP 78±23% and end of aPP 72±20%, p=0.85) or in the aPP-SP group (baseline 59±14%, end of aPP 59±15% and end of SP 54±13%, p=0.67). In the whole cohort, P aO2 :F IO2 increased from 133±44 mmHg at baseline to 183±66 mmHg in aPP (p=0.003) and decreased to 129±49 mmHg in SP (p=0.03). Conclusion: In spontaneously breathing nonintubated COVID-19 patients with ARF, aPP was not associated with a decrease of lung ventilation inhomogeneity assessed by EIT, despite an improvement in oxygenation.

Ultra-lung-protective ventilation and biotrauma in severe ARDS patients on veno-venous extracorporeal membrane oxygenation: a randomized controlled study.

BACKGROUND: Ultra-lung-protective ventilation may be useful during veno-venous extracorporeal membrane oxygenation (vv-ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator-induced lung injury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluated by numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilator strategies on vv-ECMO. METHODS: This is a prospective randomized controlled study. Patients were randomized to receive during 48 h either ultra-lung-protective ventilation combining very low tidal volume (1-2 mL/kg of predicted body weight), low respiratory rate (5-10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung-protective-ventilation which followed the ECMO arm of the EOLIA trial (control group). RESULTS: The primary outcome was the alveolar concentrations of interleukin-1-beta, interleukin-6, interleukin-8, surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin-2 48 h after randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratory rate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra-lung-protective group. None of the concentrations of the pre-specified biomarkers differed between the two groups 48 h after randomization. However, a trend to higher 60-day mortality was observed in the ultra-lung-protective group compared to the control group (45 vs 17%, p = 0.06). CONCLUSIONS: Despite a significant reduction in the mechanical power, ultra-lung-protective ventilation during 48 h did not reduce biotrauma in patients with vv-ECMO-supported ARDS. The impact of this ventilation strategy on clinical outcomes warrants further investigation. Trial registration Clinical trial registered with www. CLINICALTRIALS: gov ( NCT03918603 ). Registered 17 April 2019.

Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis.

The survival rate after cardiac arrest (CA) remains low. The utilization of extracorporeal life support is proposed to improve management. However, this resource-intensive tool is associated with complications and must be used in selected patients. We performed a meta-analysis to determine predictive factors of survival. Among the 81 studies included, involving 9256 patients, survival was 26.2% at discharge and 20.4% with a good neurologic outcome. Meta-regressions identified an association between survival at discharge and lower lactate values, intrahospital CA, and lower cardio pulmonary resuscitation (CPR) duration. After adjustment for age, intrahospital CA, and mean CPR duration, an initial shockable rhythm was the only remaining factor associated with survival to discharge (ß = 0.02, 95% CI: 0.007-0.02; p = 0.0004).

Early assessment of patients with COVID-19 and dyspnea using lung ultrasound scoring. / Evaluación precoz mediante ecografía pulmonar de pacientes con disnea por COVID-19.

OBJECTIVES: The main objective was to evaluate the precision of the Modified Lung Ultrasound (MLUS score) for predicting the need for respiratory support in the first 48 hours in patients with dyspnea due to the coronavirus disease 2019 (COVID-19). The secondary objectives were 1) to compare the MLUS and National Early Warning Score 2 (NEWS2), as well as the combination of both scores, as predictors of severity according to the World Health Organization (WHO) Ordinal Scale for Clinical Improvement; and 2) to compare severity assessed by ultrasound scoring to severity assessed by lung computed tomography (CT). MATERIAL AND METHODS: Multicenter prospective observational cohort study conducted from March 30 to April 30, 2020, in 2 university hospitals. Adult patients with dyspnea due to COVID-19 were included. An initial lung ultrasound was performed, and the results of MLUS, NEW2, and lung CT evaluations were recorded. Patients were classified by risk according to the WHO scale at 48 hours, as follows: low risk (score less than 5) or high risk (score of 5 or more). RESULTS: A total of 100 patients were included: 35 (35%) were classified as low risk and 65 (65%) as high risk. The correlation between the MLUS and WHO assessments was positive and very high (Spearman rank correlation 􀁕 = 0.832; P .001). The area under the receiver operating characteristic curves of the MLUS, NEW2 and combined ultrasound scores, in relation to prediction of risk classification were, respectively, 0.96 (0.93-0.99), 0.89 (0.82-0.95) and 0.98 (0.96-1.0). The MLUS and lung CT assessments were correlated. CONCLUSION: An early lung ultrasound score can predict clinical severity in patients with dyspnea due to COVID-19.

OBJETIVO: El objetivo principal fue evaluar la precisión de la escala de ecografía pulmonar modificada (MLUS) para predecir la necesidad de soporte respiratorio en las primeras 48 horas en pacientes con disnea por COVID-19. Los objetivos secundarios fueron comparar la escala MLUS con la escala National Early Warning Score 2 (NEW2) y la combinación de ambas para predecir la gravedad según la escala de la OMS y comparar las escalas de gravedad calculadas por ecografía y tomografía computarizada (TC) pulmonar. METODO: Estudio observacional de cohortes prospectivo multicéntrico realizado desde 30 de marzo al 30 de abril de 2020 en 2 hospitales universitarios. Se incluyeron pacientes adultos con disnea por COVID-19. Se les realizó una ecografía pulmonar inicial y se calculó la escala MLUS, escala NEW2 y la escala de gravedad calculada por TC pulmonar. Los pacientes se clasificaron como de riesgo bajo (BR) si 5 puntos o de riesgo alto (AR) si 5 puntos según la escala de la OMS a las 48 horas. RESULTADOS: Se incluyeron 100 pacientes, 35 (35%) fueron de BR y 65 (65%) de AR. La correlación entre la escala MLUS y las puntuaciones de la escala ordinal de la OMS fue positiva y muy alta (rho de Spearman = 0,832; p 0,001). El área bajo la curva COR de la escala MLUS, NEW2 y combinada fue de 0,96 (0,93-0,99), 0,89 (0,82-0,95) y 0,98 (0,96-1,0), respectivamente, para predecir el grupo de RA. Hubo relación entre las escalas MLUS y lesiones pulmonares en la TC. CONCLUSIONES: Una ecografía pulmonar inicial puede predecir la gravedad clínica de los pacientes con disnea por COVID-19.

Oesophageal pressure as a surrogate of pleural pressure in mechanically ventilated patients.

BACKGROUND: Oesophageal pressure (P oes) is used to approximate pleural pressure (P pl) and therefore to estimate transpulmonary pressure (P L). We aimed to compare oesophageal and regional pleural pressures and to calculate transpulmonary pressures in a prospective physiological study on lung transplant recipients during their stay in the intensive care unit of a tertiary university hospital. METHODS: Lung transplant recipients receiving invasive mechanical ventilation and monitored by oesophageal manometry and dependent and nondependent pleural catheters were investigated during the post-operative period. We performed simultaneous short-time measurements and recordings of oesophageal manometry and pleural pressures. Expiratory and inspiratory P L were computed by subtracting regional P pl or P oes from airway pressure; inspiratory P L was also calculated with the elastance ratio method. RESULTS: 16 patients were included. Among them, 14 were analysed. Oesophageal pressures correlated with dependent and nondependent pleural pressures during expiration (R2=0.71, p=0.005 and R2=0.77, p=0.001, respectively) and during inspiration (R2=0.66 for both, p=0.01 and p=0.014, respectively). P L values calculated using P oes were close to those obtained from the dependent pleural catheter but higher than those obtained from the nondependent pleural catheter both during expiration and inspiration. CONCLUSIONS: In ventilated lung transplant recipients, oesophageal manometry is well correlated with pleural pressure. The absolute value of P oes is higher than P pl of nondependent lung regions and could therefore underestimate the highest level of lung stress in those at high risk of overinflation.

Cannabinoid hyperemesis syndrome in two French emergency departments: a prospective cohort.

Chronic cannabis use can be associated with uncontrollable vomiting and abdominal pain. Diagnostic criteria for cannabinoid hyperemesis syndrome (CHS) were defined in 2012 by Simonetto et al. The objectives of this study were to describe the prevalence of CHS, the patients' epidemiological characteristics, and to show the difficulties encountered in caring for these patients in emergency departments, the extent of health care and an unsuitable follow-up in general practices. A prospective cohort of patients with CHS was recruited among a target population of patients leaving the adult emergency services of the Marseille hospitals Nord and La Timone between October 2017 and July 2018, with abdominal pain syndrome of unidentified etiology. Inclusion criteria for the CHS cohort were chronic cannabis use associated with nausea and vomiting. There were 48 patients included in the CHS cohort who took cannabis daily, in a target population of 2 848 patients (i.e. 1.6%). A hot shower was the most effective symptomatic treatment in 54.2% of cases. Patients suffering from CHS spent significantly more hours in emergency departments (11 vs. 6.5), and, on average, visits were more frequent (4.9 vs. 3). 20.3% of them were hospitalized to continue pain medication. Once out of hospital, follow-up was limited, and weaning off cannabis, the only etiological treatment, was difficult to set up. Informing patients about CHS is essential, and a hot shower could be systematically proposed, thus limiting an unnecessary extent of health care. CHS is genuine, medical staff should be made aware of it in occupational training, and it should be seriously considered in health policies.

National incidence rate and related mortality for acute respiratory distress syndrome in France.

INTRODUCTION: Despite many efforts to improve mechanical ventilation strategies and the use of rescue strategies, ARDS-related mortality remains high. The primary objective of this study was to determine the incidence and 90-day mortality of ARDS patients admitted to all French ICUs following the introduction of the Berlin definition of ARDS. PATIENTS AND METHODS: The data source for this nationwide cohort study was the French national hospital database (Programme de Médicalisation des Systèmes d'Information (PMSI)), which systematically collects administrative and medical information related to all patients hospitalised and hospital stays. Patient-level data were obtained from the PMSI database for all patients admitted to an ICU from the 1st of January 2017, through the 31st of December 2017. The inclusion criteria were as follows: ICU patients ≥ 18 years old with at least one International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis code of J80 (ARDS), either as a primary diagnosis or a secondary diagnosis, during their ICU stay. RESULTS: A total of 12,846 ICU adult patients with ARDS were included. The crude incidence of ARDS was 24.6 per 100,000 person-years, varying with age from 6.7 per 100,000 person-years for those 18 through 40 years of age to 51.9 per 100,000 person-years for those 68 through 76 years of age. The in-hospital mortality rate was 51.1%. Day-90 mortality (day-1 being the ICU admission) was 51.2% and increased with age from 29.0% for patients 18 through 40 years of age to 69.3% for patients 77 years of age or older (p < 0.001). Only 53.9% of the survivors were transferred home directly after hospital discharge. CONCLUSIONS: The incidence and mortality of ARDS in adults in France are higher than that generally reported in other countries.

Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit.

The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emergency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Intensivists (ADARPEF), worked out guidelines for the management of central venous catheters (CVC), arterial catheters and dialysis catheters in intensive care unit. For adult patients: Using GRADE methodology, 36 recommendations for an improved catheter management were produced by the 22 experts. Recommendations regarding catheter-related infections' prevention included the preferential use of subclavian central vein (GRADE 1), a one-step skin disinfection(GRADE 1) using 2% chlorhexidine (CHG)-alcohol (GRADE 1), and the implementation of a quality of care improvement program. Antiseptic- or antibiotic-impregnated CVC should likely not be used (GRADE 2, for children and adults). Catheter dressings should likely not be changed before the 7th day, except when the dressing gets detached, soiled or impregnated with blood (GRADE 2- adults). CHG dressings should likely be used (GRADE 2+). For adults and children, ultrasound guidance should be used to reduce mechanical complications in case of internal jugular access (GRADE 1), subclavian access (Grade 2) and femoral venous, arterial radial and femoral access (Expert opinion). For children, an ultrasound-guided supraclavicular approach of the brachiocephalic vein was recommended to reduce the number of attempts for cannulation and mechanical complications. Based on scarce publications on diagnostic and therapeutic strategies and on their experience (expert opinion), the panel proposed definitions, and therapeutic strategies.

Optimal Timing of Intervention in NSTE-ACS Without Pre-Treatment: The EARLY Randomized Trial.

OBJECTIVES: The aim of this study was to compare a delayed and a very early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) without pre-treatment. BACKGROUND: The optimal delay of the invasive strategy in patients with NSTE-ACS remains debated and has never been investigated in patients not pre-treated with P2Y12-adenosine diphosphate receptor antagonists. METHODS: A prospective, open-label, randomized controlled trial was conducted. Altogether, 741 patients presenting with intermediate- or high-risk NSTE-ACS intended for an invasive strategy were included. The modified intention-to-treat analysis was composed of 709 patients after 32 withdrew consent. Patients were randomized 1:1 to the delayed invasive group (DG) (n = 363) with coronary angiography (CA) performed 12 to 72 h after randomization or the very early invasive group (EG) (n = 346) with CA within 2 h. No pre-treatment with a loading dose of a P2Y12-adenosine diphosphate receptor antagonist was allowed before CA. The primary endpoint was the composite of cardiovascular death and recurrent ischemic events at 1 month, as determined by a blinded adjudication committee. RESULTS: Most patients had high-risk NSTE-ACS in both groups (93% in the EG vs. 92.5% in the DG). The median time between randomization and CA was 0 h (interquartile range [IQR]: 0 to 1 h) in the EG group and 18 h (IQR: 11 to 23 h) in the DG. The primary endpoint rate was significantly lower in the EG (4.4% vs. 21.3% in the DG; hazard ratio: 0.20; 95% confidence interval: 0.11 to 0.34; p < 0.001), driven by a reduction in recurrent ischemic events (19.8% vs. 2.9%; p < 0.001). No difference was observed for cardiovascular death. CONCLUSIONS: Without pre-treatment, a very early invasive strategy was associated with a significant reduction in ischemic events at the time of percutaneous coronary intervention in patients with intermediate- and high-risk NSTE-ACS. (Early or Delayed Revascularization for Intermediate and High-Risk Non ST-Elevation Acute Coronary Syndromes; NCT02750579).

Prevalence and Risk Factors for Thrombotic Complications Following Venovenous Extracorporeal Membrane Oxygenation: A CT Scan Study.

OBJECTIVES: The aims of this study were to: 1) analyze the cannula-associated deep vein thrombosis frequency after venovenous extracorporeal membrane oxygenation using a CT scan and 2) identify the associated risk factors for cannula-associated deep vein thrombosis. DESIGN: Retrospective observational analysis at a single center. SETTING: Tertiary referral university teaching hospital. PATIENTS: Patients under venovenous extracorporeal membrane oxygenation with a femorofemoral or femorojugular cannulation admitted for acute respiratory distress syndrome or primary graft dysfunction after pulmonary transplantation. CT scan was performed within 4 days after decannulation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 105 of 228 patients screened. Bacterial pneumonia was the main indication of venovenous extracorporeal membrane oxygenation (46.7%). CT scans were performed at a median of 2 days (1-3 d) after decannulation. Cannula-associated deep vein thrombosis was found in 75 patients (71.4%) despite it having a mean activated partial thromboplastin time ratio of 1.60 ± 0.31. Femorofemoral cannulation induced femoral cannula-associated deep vein thrombosis more frequently than femorojugular cannulation (69.2% vs 63.1%, respectively; p = 0.04). Seventeen of the 105 patients (16.2%) had a pulmonary embolism. Multivariate logistic regression analysis showed that higher the percentage of thrombocytopenia less than 100 G/L during extracorporeal membrane oxygenation period, lower the risk for developing cannula-associated deep vein thrombosis (hazard ratio, 0.98; 95% CI, 0.98-1.00; p = 0.02). CONCLUSIONS: Cannula-associated deep vein thrombosis after venovenous extracorporeal membrane oxygenation is a frequent complication. This plead for a systematic vascular axis imaging after venovenous extracorporeal membrane oxygenation. Thrombocytopenia is associated with a reduction in the occurrence of thrombotic events.

Herpes simplex virus and Cytomegalovirus reactivation among severe ARDS patients under veno-venous ECMO.

BACKGROUND: Herpesviridae reactivation among non-immunocompromised critically ill patients is associated with impaired prognosis, especially during acute respiratory distress syndrome (ARDS). However, little is known about herpes simplex virus (HSV) and Cytomegalovirus (CMV) reactivation occurring in patients with severe ARDS under veno-venous extracorporeal membrane oxygenation (ECMO). We tried to determine the frequency of Herpesviridae reactivation and its impact on patients' prognosis during ECMO for severe ARDS. RESULTS: During a 5-year period, 123 non-immunocompromised patients with a severe ARDS requiring a veno-venous ECMO were included. Sixty-seven patients (54%) experienced HSV and/or CMV reactivation during ECMO course (20 viral co-infection, 40 HSV alone, and 7 CMV alone). HSV reactivation occurred earlier than CMV after the beginning of MV [(6-15) vs. 19 (13-29) days; p < 0.01] and after ECMO implementation [(2-8) vs. 14 (10-20) days; p < 0.01]. In univariate analysis, HSV/CMV reactivation was associated with a longer duration of mechanical ventilation [(22-52.5) vs. 17.5 (9-28) days; p < 0.01], a longer duration of ECMO [15 (10-22.5) vs. 9 (5-14) days; p < 0.01], and a prolonged ICU [29 (19.5-47.5) vs. 16 (9-30) days; p < 0.01] and hospital stay [44 (29-63.5) vs. 24 (11-43) days; p < 0.01] as compared to non-reactivated patients. However, in multivariate analysis, viral reactivation remained associated with prolonged MV only. When considered separately, both HSV and CMV reactivation were associated with a longer duration of MV as compared to non-reactivation patients [29 (19.5-41) and 28 (20.5-37), respectively, vs. 17.5 (9-28) days; p < 0.05]. Co-reactivation patients had a longer duration of MV [58.5 (38-72.3); p < 0.05] and ICU stay [51.5 (32.5-69) vs. 27.5 (17.75-35.5) and 29 (20-30.5), respectively] as compared to patients with HSV or CMV reactivation alone. In multivariate analysis, HSV reactivation remained independently associated with a longer duration of MV and hospital length of stay. CONCLUSIONS: Herpesviridae reactivation is frequent among patients with severe ARDS under veno-venous ECMO and is associated with a longer duration of mechanical ventilation. The direct causative link between HSV and CMV reactivation and respiratory function worsening under ECMO remains to be confirmed.

Long-term neurocognitive outcome is not worsened by of the use of venovenous ECMO in severe ARDS patients.

BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is associated with a significant morbidity. There is the need to investigate long-term cognitive outcome among ARDS survivors treated with VV-ECMO. We aimed to compare the prevalence of long-term cognitive dysfunction and neuropsychological impairment using a highly specific test in severe ARDS survivors treated or not treated with VV-ECMO. METHODS: Severe ARDS survivors treated between 2011 and 2017 in an ECMO Regional Referral Center were prospectively evaluated 2 years after their ICU discharge. Patients underwent an in-person interview and examination. The primary outcome was cognitive function, assessed by the Wechsler Adult Intelligence Scale 4th edition (WAIS-IV). Secondary outcomes included anxiety, depression, post-traumatic stress disorder (PTSD) and quality-of-life. RESULTS: We investigated 40 consecutive patients surviving from severe ARDS treated (N = 22) or not (N = 18) with VV-ECMO at a median [interquartile range] of 20 [17-22] and 22 [18-23] months after ICU discharge, respectively. Regarding the main outcome, cognitive function was below normal ranges in 12 (55%) ECMO patients and 10 (56%) non-ECMO patients (p = 0.95). Eight (36%) ECMO patients had moderate-to-severe depressive symptoms as compared with 7 (39%) non-ECMO patients (p = 0.87). Twelve (55%) ECMO patients and eight (44%) non-ECMO patients had moderate-to-severe anxiety symptoms (p = 0.53). Seven (33%) ECMO patients and eight (44%) non-ECMO patients presented a PTSD (p = 0.48). Health-related quality of life did not differ between the two groups. CONCLUSIONS: Using the WAIS-IV, VV-ECMO treatment does not appear to worsen long-term cognitive and neuropsychological outcomes in severe ARDS patients.

Multidrug-resistant Pseudomonas aeruginosa and mortality in mechanically ventilated ICU patients.

BACKGROUND: The link between bacterial resistance and prognosis remains controversial. Predominant pathogen causing ventilator-associated pneumonia (VAP) is Pseudomonas aeruginosa (Pa), which has increasingly become multidrug resistant (MDR). The aim of this study was to evaluate the relationship between MDR VAP Pa episodes and 30-day mortality. METHODS: From a longitudinal prospective French multicenter database (2010-2016), Pa VAP onset and physiological data were recorded. MDR was defined as non-susceptibility to at least 1 agent in 3 or more antimicrobial categories. To analyze if MDR episodes were associated with greater in-hospital 30-day mortality, we performed a multivariate survival analysis using the multivariate nonlinear frailty model. RESULTS: A total of 230 patients presented 286 Pa VAP. A maximum of 3 episodes per patient was observed; 73 episodes were MDR and 213 were susceptible. In the multivariate model, factors independently associated with 30-day mortality included hospitalization in the 6 months preceding the first episode (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.50-3.60; P = .0002), chronic renal failure (HR, 2.34; 95% CI, 1.15-4.77; P = .0196), and Pa VAP recurrence (HR, 2.29; 95% CI, 1.79-4.87; P = .032). Finally, MDR Pa VAP was not associated with death (HR, 0.87; 95% CI; 0.52-1.45; P = .59). CONCLUSIONS: This study did not identify a relationship between the resistance profile of Pseudomonas aeruginosa and mortality.