Sodium Bicarbonate Versus Sodium Chloride for Preventing Contrast-Associated Acute Kidney Injury in Critically Ill Patients: A Randomized Controlled Trial.

OBJECTIVES: To test whether hydration with bicarbonate rather than isotonic sodium chloride reduces the risk of contrast-associated acute kidney injury in critically ill patients. DESIGN: Prospective, double-blind, multicenter, randomized controlled study. SETTING: Three French ICUs. PATIENTS: Critically ill patients with stable renal function (n = 307) who received intravascular contrast media. INTERVENTIONS: Hydration with 0.9% sodium chloride or 1.4% sodium bicarbonate administered with the same infusion protocol: 3 mL/kg during 1 hour before and 1 mL/kg/hr during 6 hours after contrast medium exposure. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the development of contrast-associated acute kidney injury, as defined by the Acute Kidney Injury Network criteria, 72 hours after contrast exposure. Patients randomized to the bicarbonate group (n = 151) showed a higher urinary pH at the end of the infusion than patients randomized to the saline group (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.0001). The frequency of contrast-associated acute kidney injury was similar in both groups: 52 patients (33.3%) in the saline group and 53 patients (35.1%) in the bicarbonate group (absolute risk difference, -1.8%; 95% CI [-12.3% to 8.9%]; p = 0.81). The need for renal replacement therapy (five [3.2%] and six [3.9%] patients; p = 0.77), ICU length of stay (24.7 ± 22.9 and 23 ± 23.8 d; p = 0.52), and mortality (25 [16.0%] and 24 [15.9%] patients; p > 0.99) were also similar between the saline and bicarbonate groups, respectively. CONCLUSIONS: Except for urinary pH, none of the outcomes differed between the two groups. Among ICU patients with stable renal function, the benefit of using sodium bicarbonate rather than isotonic sodium chloride for preventing contrast-associated acute kidney injury is marginal, if any.

Extracorporeal CO2 removal in acute exacerbation of COPD unresponsive to non-invasive ventilation.

BACKGROUND: The gold-standard treatment for acute exacerbation of chronic obstructive pulmonary disease (ae-COPD) is non-invasive ventilation (NIV). However, NIV failures may be observed, and invasive mechanical ventilation (IMV) is required. Extracorporeal CO2 removal (ECCO2R) devices can be an alternative to intubation. The aim of the study was to assess ECCO2R effectiveness and safety. METHODS: Patients with consecutive ae-COPD who experienced NIV failure were retrospectively assessed over two periods of time: before and after ECCO2R device implementation in our ICU in 2015 (Xenios AG). RESULTS: Both groups (ECCO2R: n=26, control group: n=25) were comparable at baseline, except for BMI, which was significantly higher in the ECCO2R group (30 kg/m² vs 25 kg/m²). pH and PaCO2 significantly improved in both groups. The mean time on ECCO2R was 5.4 days versus 27 days for IMV in the control group. Four patients required IMV in the ECCO2R group, of whom three received IMV after ECCO2R weaning. Seven major bleeding events were observed with ECCO2R, but only three led to premature discontinuation of ECCO2R. Eight cases of ventilator-associated pneumonia were observed in the control group. Mean time spent in the ICU and mean hospital stay in the ECCO2R and control groups were, respectively, 18 vs 30 days, 29 vs 49 days, and the 90-day mortality rates were 15% vs 28%. CONCLUSIONS: ECCO2R was associated with significant improvement of pH and PaCO2 in patients with ae-COPD failing NIV therapy. It also led to avoiding intubation in 85% of cases, with low complication rates. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT04882410. Date of registration 12 May 2021, retrospectively registered.https://www.clinicaltrials.gov/ct2/show/NCT04882410.

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study.

INTRODUCTION: Because of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients. MATERIAL AND METHODS: This single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10-15 l/min of oxygen with a non-rebreather mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation. RESULTS: CPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54-71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30-40) and median SpO2 was 92% (90-95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1-5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated. CONCLUSIONS: CPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation.

Semi-quantitative cultures of throat and rectal swabs are efficient tests to predict ESBL-Enterobacterales ventilator-associated pneumonia in mechanically ventilated ESBL carriers.

PURPOSE: In ICU patients with carriage of extended spectrum beta-lactamase producing Enterobacterales (ESBL-E) and suspected Gram-negative bacilli ventilator-associated pneumonia (GNB-VAP), the quantification of the rectal and throat ESBL-E carriage might predict the ESBL-E involvement in GNB-VAP. Our aim was to evaluate whether a semi-quantitative assessment of rectal/throat ESBL-E carriage can predict ESBL-E-associated VAP in medical ICU patients. METHODS: From May 2014 to May 2017, all ESBL-E carriers had a semi-quantitative assessment of ESBL-E density in swabs cultures. For those who developed GNB-VAP (diagnosed using bronchoalveolar lavage or plugged telescopic catheter with significant quantitative culture), the last positive swab collected at least 48 h before GNB-VAP onset was selected. Clinical data were extracted from a prospectively collected database. RESULTS: Among 365 ESBL-E carriers, 82 developed 107 episodes of GNB-VAP (ESBL-E VAP, n = 50; and non-ESBL-E GNB-VAP, n = 57) after 13 days of mechanical ventilation in median. Antimicrobials use before VAP onset was similar between groups. The last swabs were collected 5 days in median before VAP onset. ESBL-E. coli carriers developed ESBL-E VAP less frequently (n = 13, 34%) than others (n = 32, 67.3%, p < .01). Throat swab positivity (39 (78%) vs. 12 (23%), p < .01) was more frequent for ESBL-E VAP. ESBL-E VAP was associated with significantly higher ESBL-E density in rectal swabs. In multivariate models, non-E. coli ESBL-E carriage and rectal ESBL-E carriage density, or throat carriage, remained associated with ESBL-E VAP. CONCLUSION: In carriers of ESBL-E other than E. coli, ESBL-E throat carriage or a high-density ESBL-E rectal carriage are risk factors of ESBL-E VAP in case of GNB-VAP.

Impact of natural light exposure on delirium burden in adult patients receiving invasive mechanical ventilation in the ICU: a prospective study.

OBJECTIVE: To determine whether potential exposure to natural light via windows is associated with reduced delirium burden in critically ill patients admitted to the ICU in a single room. DESIGN: Prospective single-center study. SETTING: Medical ICU of a university hospital, Paris, France. PATIENTS: Adult patients receiving invasive mechanical ventilation. METHODS: Consecutive patients admitted to a single room with (LIGHT group) or without (DARK group) exposure to natural light via windows were evaluated for delirium. The primary endpoint was the incidence of delirium. Main secondary endpoints included incidence of severe agitation intervened with antipsychotics and incidence of hallucinations. RESULTS: A total of 195 patients were included (LIGHT group: n = 110; DARK group: n = 85). The incidence of delirium was similar in the LIGHT group and the DARK group (64% vs. 71%; relative risk (RR) 0.89, 95% CI 0.73-1.09). Compared with the DARK group, patients from the LIGHT group were less likely to be intervened with antipsychotics for agitation episodes (13% vs. 25%; RR 0.52, 95% CI 0.27-0.98) and had less frequent hallucinations (11% vs. 22%; RR 0.49, 95% CI 0.24-0.98). In multivariate logistic regression analysis, natural light exposure was independently associated with a reduced risk of agitation episodes intervened with antipsychotics (adjusted odds ratio = 0.39; 95% CI 0.17-0.88). CONCLUSION: Admission to a single room with potential exposure to natural light via windows was not associated with reduced delirium burden, as compared to admission to a single room without windows. However, natural light exposure was associated with a reduced risk of agitation episodes and hallucinations.

Superiority of transcutaneous CO2 over end-tidal CO2 measurement for monitoring respiratory failure in nonintubated patients: A pilot study.

PURPOSE: Arterial blood gas measurement is frequently performed in critically ill patients to diagnose and monitor acute respiratory failure. At a given metabolic rate, carbon dioxide partial pressure (PaCO2) is entirely determined by CO2 elimination through ventilation. Transcutaneous partial pressure of carbon dioxide (PtcCO2) monitoring permits a noninvasive and continuous estimation of arterial CO2 tension (PaCO2). The accuracy of PtcCO2, however, has not been well studied. To assess the accuracy of different CO2 monitoring methods, we compared PtcCO2 and end-tidal CO2 concentration (EtCO2) to PaCO2 measurements in nonintubated intensive care unit (ICU) patients with acute respiratory failure. METHODS: During a 2-month period, we conducted a prospective observational cohort study in 25 consecutive nonintubated and spontaneously breathing patients admitted to our ICU. Arterial blood gases were measured at study inclusion, 30, 60, and 120 minutes later. At each sampling time, EtCO2 was continuously monitored using a Philips Smart Capnoline Plus, and PtcCO2 was measured using was measured using SenTec device. The aim of the study was to assess agreement between PtcCO2 and PaCO2 and between EtCO2 and PaCO2 in nonintubated ICU patients with acute respiratory failure. Bland-Altman techniques and Pearson correlation coefficients were used. The differences over time (at 30, 60, and 120 minutes) between PaCO2 and EtCO2 and between PtcCO2 and PaCO2 were evaluated using 1-way analysis of variance. RESULTS: Transcutaneous partial pressure of carbon dioxide and PaCO2 were well correlated (R = 0.97), whereas the correlation between EtCO2 and PaCO2 was poor (R = 0.62) probably due to the presence of an alveolar dead space in a few patients, most notably in the group with chronic obstructive pulmonary disease. The difference over time remained stable for both PaCO2 vs EtCO2 (analysis of variance; P = .88) and PaCO2 vs PtcCO2 (P = .93). CONCLUSION: We found large differences between EtCO2 and Paco2 in spontaneously breathing nonintubated ICU patients admitted for acute respiratory failure. Our study argues against the use of EtCO2 monitoring in such patients but raises the possibility that PtcCO2 measurement may provide reasonable estimates of PaCO2.