New Noninvasive Method for the Assessment of Central Venous Oxygen Saturations in Critically Ill Patients.

OBJECTIVES: To compare noninvasive external jugular vein oxygen saturations (SjvO2) and central venous oxygen saturation (ScvO2) from a blood sample in patients admitted to the intensive care unit. DESIGN: A prospective, comparative, monocentric clinical trial design was used. SETTING: The study was performed in the Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva (Switzerland). PARTICIPANTS: A total of 79 patients were enrolled; patients with confirmed COVID-19 infection requiring invasive mechanical ventilation (patients with COVID-19, n = 36) and patients after liver transplantation (posttransplant patients, n = 43). INTERVENTIONS: Simultaneous measurement of SjvO2 by near-infrared spectroscopy and ScvO2 from central venous blood samples using a blood gas analyzer in stable hemodynamic conditions. MEASUREMENTS AND MAIN RESULTS: A strong linear correlation was evidenced in both the COVID-19 and posttransplant patient groups between the 2 modalities. The Bland-Altman analysis showed low bias in accordance with low percentage error in both groups (0.57% and 8.09% for patients with COVID-19; 0.00% and 13.72% for posttransplant patients). CONCLUSIONS: Central venous oxygen saturation can be estimated reasonably by the continuous noninvasive measurement of SjvO2 using near-infrared spectroscopy.

[Mechanical management of refractory form of heart failure]. / Prise en charge mécanique de l'insuffisance cardiaque avancée.

Although the initial management of heart failure is essentially pharmacological, the use of mechanical circulatory support may become necessary in advanced forms. In cardiogenic shock, temporary mechanical circulatory support should be considered, while in more stable forms of advanced heart failure, implantation of a long-term left ventricular assist device (LVAD) can prolong survival and improve patient's quality of life. Recent improvements in LVAD technology have reduced post-implant complications, but the procedure is not without risk and requires close clinical follow-up.

Bien que la prise en charge initiale de l'insuffisance cardiaque soit essentiellement pharmacologique, le recours à des assistances circulatoires mécaniques peut devenir nécessaire dans les formes dites avancées. Dans le choc cardiogénique, l'utilisation d'assistances circulatoires mécaniques temporaires est à considérer alors que pour les formes d'insuffisance cardiaque avancée mieux stabilisées, l'implantation d'une assistance ventriculaire gauche de longue durée (Left Ventricular Assist Device - LVAD) permet de prolonger la survie et d'améliorer la qualité de vie des patients. Les améliorations technologiques récentes des LVAD ont permis de diminuer les complications, mais cette intervention n'est pas sans risque et nécessite un suivi clinique rapproché.

Oesophageal balloon positioning by echocardiography to guide positive pressure ventilation.

Understanding the respiratory mechanics of ARDS patients is crucial to avoid ventilator-induced lung injury (VILI), and this is much more challenging if not only lung compliance is altered but the whole compliance of the respiratory system is abnormal, as in obese patients. We face this problem daily in the ICU, and to optimize ventilation, we estimate respiratory mechanics using an oesophageal balloon. The balloon position is crucial to assess reliable values. In the present technical note, we describe the use of echocardiography to confirm the correct position of this instrument.

[Cardiac surgery in the time of COVID19 - A narrative of three very unusual cases and lessons learned]. / Chirurgie cardiaque au temps du Covid-19 - Récit de trois cas très inhabituels et leçons retenues.

COVID19 altered and impacted medical and surgical practice around the world. Standard of care and routine procedures are disrupted. Majors shift in personnel, and ad hoc new team as well as delocalization and working with new infrastructures are further challenges to be dealt with. This review of three very unusual scenarios illustrates pitfalls and dangers harbored in the re-shaped landscape of COVID19 exemplifying the narrow path bridging from the medical and surgical comfort zone to uncharted territory and eventually leading to collateral damage.

Le Covid-19 a profondément modifié et sévèrement impacté les pratiques médicales et chirurgicales à long terme. Les standards de prise en charge et les procédures de routine sont altérés, voire perturbés. Des mutations majeures au niveau du personnel et des équipes de même que la délocalisation ou le travail avec de nouvelles infrastructures sont autant de défis à relever, encore aujourd'hui. Trois scénarios inhabituels illustrent les pièges et les dangers qui se cachent dans le paysage marqué par le Covid-19. Ces exemples démontrent la marge étroite entre la zone de confort médicale et chirurgicale classique et l'appréhension d'une situation inhabituelle qui risque d'entraîner des dommages collatéraux pour les patients.

Thiamine, Ascorbic Acid, and Hydrocortisone As a Metabolic Resuscitation Cocktail in Sepsis: A Meta-Analysis of Randomized Controlled Trials With Trial Sequential Analysis.

OBJECTIVES: Sepsis is a common condition in the ICU. Despite much research, its prognosis remains poor. In 2017, a retrospective before/after study reported promising results using a combination of thiamine, ascorbic acid, and hydrocortisone called "metabolic resuscitation cocktail" and several randomized controlled trials assessing its effectiveness were performed. DESIGN: We conducted a systematic review and meta-analysis of randomized controlled trials in septic ICU patients to assess the effects of this combination therapy. SETTING: PubMed, Embase, and the Cochrane library databases were searched from inception to March of 2021. Data were extracted independently by two authors. The main outcome was the change in Sequential Organ Failure Assessment score within 72 hours. Secondary outcomes included renal composite endpoints (acute kidney injury) Kidney Disease - Improving Global Outcome organization stage 3 or need for renal replacement therapy, vasopressor duration, and 28-day mortality. SUBJECTS: We included randomized controlled trials with patients admitted to the ICU with sepsis or septic shock. INTERVENTION: The trials compared a combination of thiamine, ascorbic acid, and hydrocortisone to standard care or placebo in patients admitted to ICU with sepsis or septic shock. MEASUREMENTS AND MAIN RESULTS: We included eight randomized controlled trials (n = 1,335 patients). Within 72 hours, the median of mean improvement was -1.8 and -3.2 in the control and intervention groups, respectively (eight randomized controlled trials, n = 1,253 patients); weighted mean difference -0.82 (95% CI, -1.15 to -0.48). Data were homogeneous and the funnel plot did not suggest any publication bias. Duration of vasopressor requirement was significantly reduced in the intervention group (six randomized controlled trials). There was no evidence of a difference regarding the ICU mortality and the renal composite outcome (acute kidney injury KDIGO 3 or need for renal replacement therapy, seven randomized controlled trials). CONCLUSIONS: Metabolic resuscitation cocktail administrated in ICU septic patients improves change in Sequential Organ Failure Assessment score within 72 hours. However, this improvement is modest and its clinical relevance is questionable. The impact on renal failure and mortality remains unclear.

Very low blood flow carbon dioxide removal system is not effective in a chronic obstructive pulmonary disease exacerbation setting.

Extracorporeal carbon dioxide removal (ECCO2 R) is a low blood flow veno-venous extracorporeal membrane oxygenation technique that provides artificial blood CO2 removal. Recently, a new ECCO2 R system (PrismaLung), providing very low blood flow has been commercialized. The aim of this study is to report its use in severe chronic obstructive pulmonary disease (COPD) patients needing an ECCO2 R therapy. Six severe COPD patients with acute exacerbation leading to refractory hypercapnic respiratory acidosis were treated with ECCO2 R therapy. Two different systems were used: a PrismaLung system and a conventional ECCO2 R device. The maximum blood flow provided by PrismaLung was significantly lower than that with the conventional ECCO2 R system. In three patients initially treated with PrismaLung, there were no improvements in pH, PaCO2 , or RR. Thus, the therapy was switched to a conventional ECCO2 R system in these three patients, and three others were treated from the outset by the conventional ECCO2 R system, providing significant improvement in pH, PaCO2 , and RR. The present retrospective study describes the first use of PrismaLung in severe COPD patients with acute exacerbation. When compared with a higher blood flow ECCO2 R system, our results show that this novel, very low-flow device is not able to remove sufficient CO2 , normalize pH or decrease respiratory rate.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

The use of extracorporeal carbon dioxide removal in acute chronic obstructive pulmonary disease exacerbation: a narrative review.

Chronic obstructive pulmonary disease (COPD) exacerbation induces hypercapnic respiratory acidosis. Extracorporeal carbon dioxide removal (ECCO2R) aims to eliminate blood carbon dioxide (CO2) in order to reduce adverse effects from hypercapnia and the related acidosis. Hypercapnia has deleterious extra-pulmonary consequences in increasing intracranial pressure and inducing and/or worsening right heart failure. During COPD exacerbation, the use of ECCO2R may improve the efficacy of non-invasive ventilation (NIV) in terms of CO2 removal, decrease respiratory rate and reduce dynamic hyperinflation and intrinsic positive end expiratory pressure, which all contribute to increasing dead space. Moreover, ECCO2R may prevent NIV failure while facilitating the weaning of intubated patients from mechanical ventilation. In this review of the literature, the authors will present the current knowledge on the pathophysiology related to COPD, the principles of the ECCO2R technique and its role in acute and severe decompensation of COPD. However, despite technical advances, there are only case series in the literature and few prospective studies to clearly establish the role of ECCO2R in acute and severe COPD decompensation.

An unusual thrombus location in a Heartmate 3TM device with fatal outcome.

Even if the HeartMate 3TM left ventricular assist device is associated with excellent outcomes, complications, such as pump thrombosis continue to affect patients on hemodynamic support. We report the history of a 68-year-old man who underwent implantation of an HeartMate 3TM as a bridge to transplantation. Nineteen months later, he developed signs of heart failure leading to cardiogenic shock. Neither clinical examination nor parameters from the device allowed a clear-cut diagnosis. Only surgical exploration revealed the presence of clots between the polyethylene terephthalate (Dacron®) and polytetrafluoroethylene tubes. This constitutes a weakness of this device for which we propose to the manufacturer for minimal modifications to overcome the problem.

A longitudinal study highlights shared aspects of the transcriptomic response to cardiogenic and septic shock.

BACKGROUND: Septic shock (SS) and cardiogenic shock (CS) are two types of circulatory shock with a different etiology. Several studies have described the molecular alterations in SS patients, whereas the molecular factors involved in CS have been poorly investigated. We aimed to assess in the whole blood of CS and SS patients, using septic patients without shock (SC) as controls, transcriptomic modifications that occur over 1 week after ICU admission and are common to the two types of shock. METHODS: We performed whole blood RNA sequencing in 21 SS, 11 CS, and 5 SC. In shock patients, blood samples were collected within 16 h from ICU admission (T1), 48 h after ICU admission (T2), and at day 7 or before discharge (T3). In controls, blood samples were available at T1 and T2. Gene expression changes over time have been studied in CS, SS, and SC separately with a paired analysis. Genes with p value < 0.01 (Benjamini-Hochberg multiple test correction) were defined differentially expressed (DEGs). We used gene set enrichment analysis (GSEA) to identify the biological processes and transcriptional regulators significantly enriched in both types of shock. RESULTS: In both CS and SS patients, GO terms of inflammatory response and pattern recognition receptors (PRRs) were downregulated following ICU admission, whereas gene sets of DNA replication were upregulated. At the gene level, we observed that alarmins, interleukin receptors, PRRs, inflammasome, and DNA replication genes significantly changed their expression in CS and SS, but not in SC. Analysis of transcription factor targets showed in both CS and SS patients, an enrichment of CCAAT-enhancer-binding protein beta (CEBPB) targets in genes downregulated over time and an enrichment of E2F targets in genes with an increasing expression trend. CONCLUSIONS: This pilot study supports, within the limits of a small sample size, the role of alarmins, PRRs, DNA replication, and immunoglobulins in the pathophysiology of circulatory shock, either in the presence of infection or not. We hypothesize that these genes could be potential targets of therapeutic interventions in CS and SS. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02141607. Registered 19 May 2014.

Validation of the clinical frailty score (CFS) in French language.

BACKGROUND: Very old critical ill patients are a rapid expanding group. To better understand the magnitude of the challenges involved in intensive care practice for an ageing population and discuss a rational allocation of resources, healthcare practitioners need a reliable evaluation of frailty. In order to promote the adequate use of the Clinical Frailty Scale (CFS) in a wider panel of countries, we aimed to develop, validate and characterise a French (FR) version from the original English (EN) CFS. METHODS: We included participants recruited prospectively for the observational "The very old intensive care patient: A multinational prospective observation study" (VIP Study) at Geneva University Hospitals (FR speaking hospital). A FR version of the CFS was obtained by translation (EN- > FR) and back translation (FR- > EN). The final CFS-FR was then evaluated twice on the same participants with at least a 2-week interval by FR-speaking doctors and nurses. RESULTS: Inter-rater reliability was 0.87 (95%CI: 0.76-0.93) between doctors for the original CFS version and 0.76 (95%CI: 0.57-0.87) between nurses for the FR version. Inter-rater variability between doctor and nurse was 0.75 (95%CI: 0.56-0.87) for the original version, and 0.73 (95%CI: 0.52-0.85) for the FR version. Test-retest (stability) with the original vs the FR version was 0.86 (95%CI: 0.72-0.93) for doctors and 0.87 (95%CI: 0.76-0.93) for nurses. Differences between the evaluations of the CFS-EN and CSF-FR were not different from 0, with a mean difference of 0.06 (95%CI -0.24, 0.36) for the EN version and - 0.03 (95%CI -0.47, 0.41) for the FR version. Average original version ratings were slightly lower than FR version ratings, though this difference did not reach significance: -0.29 (95%CI -0.54, 0.04). CONCLUSION: In this prospective cohort of very old intensive care participants we developed and tested the basic psychometric properties (internal consistency, reproducibility) of a French version of the CFS. This manuscript provides clinically meaningful psychometric properties that have not been previously reported in any other language, including in the original EN version. The French cultural adaptation of this CFS has adequate psychometric properties for doctors or nurses to evaluate frailty in very old intensive care patients.

Journal of clinical monitoring and computing end of year summary 2018: hemodynamic monitoring and management.

Hemodynamic management is a mainstay of patient care in the operating room and intensive care unit (ICU). In order to optimize patient treatment, researchers investigate monitoring technologies, cardiovascular (patho-) physiology, and hemodynamic treatment strategies. The Journal of Clinical Monitoring and Computing (JCMC) is a well-established and recognized platform for publishing research in this field. In this review, we highlight recent advancements and summarize selected papers published in the JCMC in 2018 related to hemodynamic monitoring and management.

Identification of a transcriptome profile associated with improvement of organ function in septic shock patients after early supportive therapy.

BACKGROUND: Septic shock is the most severe complication of sepsis and this syndrome is associated with high mortality. Treatment of septic shock remains largely supportive of hemodynamics and tissue perfusion. Early changes in organ function assessed by the Sequential Organ Function Assessment (SOFA) score are highly predictive of the outcome. However, the individual patient's response to supportive therapy is very heterogeneous, and the mechanisms underlying this variable response remain elusive. The aim of the study was to investigate the transcriptome of whole blood in septic shock patients with different responses to early supportive hemodynamic therapy assessed by changes in SOFA scores within the first 48 h from intensive care unit (ICU) admission. METHODS: We performed whole blood RNA sequencing in 31 patients: 17 classified as responders (R) and 14 as non-responders (NR). Gene expression was investigated at ICU admission (time point 1, or T1), comparing R with NR [padj < 0.01; Benjamini-Hochberg (BH)] and over time from T1 to T2 (48 h later) in R and NR independently (paired analysis, padj < 0.01; BH). Then the differences in gene expression trends over time were evaluated (Mann-Whitney, P <0.01). To identify enriched biological processes, we performed an over-representation analysis based on a right-sided hypergeometric test with Bonferroni step-down as multiple testing correction (padj < 0.05). RESULTS: At ICU admission, we did not identify differentially expressed genes (DEGs) between the two groups. In the transition from T1 to T2, the activation of genes involved in T cell-mediated immunity, granulocyte and natural killer (NK) cell functions, and pathogen lipid clearance was noted in the R group. Genes involved in acute inflammation were downregulated in both groups. CONCLUSIONS: Within the limits of a small sample size, our results could suggest that early activation of genes of the adaptive immune response is associated with an improvement in organ function.

Respiratory changes in subclavian vein diameters predicts fluid responsiveness in intensive care patients: a pilot study.

The present pilot study investigated whether respiratory variation in subclavian vein (SCV) diameters correlates with fluid responsiveness in mechanically ventilated patients. Monocentric, prospective clinical study on fluid responsiveness in adult sedated, mechanically ventilated ICU patient, monitored with the PiCCO™ system (Pulsion Medical System, Germany), and requiring a fluid challenge (FC). A 10-min fluid bolus of 500 mL of 0.9% saline was administered. Cardiac output (CO) and dynamic parameters [stroke volume variation (SVV) and pulse pressure variation (PPV)] measured by transpulmonary thermodilution and pulse contour analysis (PiCCO™) as well as classical hemodynamic parameters were recorded at baseline and after FC. Fluid responsiveness was described as an increase in CO of ≥ 15%. Ultrasound measurements obtained in the subclavian long-axis view were used to calculate the SCVvariability index. A cut-off value for SCV variation for the prediction of fluid responsiveness was determined using receiver operating curve (ROC) analysis. Nine of 20 FCs (45%) induced an increase in CO of ≥ 15%. At baseline, the SCVvariability index was greater in responders than in non-responders (34.0 ± 21.4 vs. 9.0 ± 5.5; p = 0.0005). Diagnostic performance for the SCVvariability index revealed a cut-off value of 14 with a sensitivity of 100% [Confidence interval (CI) 95% (90; 100)] and a specificity of 82% [CI 95% (48; 98)] for the prediction of fluid responsiveness. Other parameters, such as SVV and PPV, could not predict fluid responsiveness. The correlation coefficient between CO variation and the SCVvariability index was 0.73 (p < 0.001). The SCVvariability index was a reliable, non-invasive parameter for the prediction of fluid responsiveness at the bedside of mechanically ventilated, critically ill patients in this pilot study.

Journal of Clinical Monitoring and Computing 2017 end of year summary: cardiovascular and hemodynamic monitoring.

Hemodynamic monitoring provides the basis for the optimization of cardiovascular dynamics in intensive care medicine and anesthesiology. The Journal of Clinical Monitoring and Computing (JCMC) is an ideal platform to publish research related to hemodynamic monitoring technologies, cardiovascular (patho)physiology, and hemodynamic treatment strategies. In this review, we discuss selected papers published on cardiovascular and hemodynamic monitoring in the JCMC in 2017.

Reproducibility of transpulmonary thermodilution cardiac output measurements in clinical practice: a systematic review.

Measuring cardiac output (CO) is an integral part of the diagnostic and therapeutic strategy in critically ill patients. During the last decade, the single transpulmonary thermodilution (TPTD) technique was implemented in clinical practice. The purpose of this paper was to systematically review and critically assess the existing data concerning the reproducibility of CO measured using TPTD (COTPTD). A total of 16 studies were identified to potentially be included in our study because these studies had the required information that allowed for calculating the reproducibility of COTPTD measurements. 14 adult studies and 2 pediatric studies were analyzed. In total, 3432 averaged CO values in the adult population and 78 averaged CO values in the pediatric population were analyzed. The overall reproducibility of COTPTD measurements was 6.1 ± 2.0 % in the adult studies and 3.9 ± 2.9 % in the pediatric studies. An average of 3 boluses was necessary for obtaining a mean CO value. Achieving more than 3 boluses did not improve reproducibility; however, achieving less than 3 boluses significantly affects the reproducibility of this technique. The present results emphasize that TPTD is a highly reproducible technique for monitoring CO in critically ill patients, especially in the pediatric population. Our findings suggest that obtaining a mean of 3 measurements for determining CO values is recommended.

The use of the oesophageal Doppler in perioperative medicine: new opportunities in research and clinical practice.

The oesophageal Doppler (OD) is a minimally invasive haemodynamic monitor used in the surgical theatre and the ICU. Using the OD, goal-directed therapy (GDT) has been shown to reduce perioperative complications in high-risk surgical patients. However, most GDT protocols currently in use are limited to stroke volume optimisation. In the present manuscript, we examine the conceptual models behind new OD-based measurements. These would provide the clinician with a comprehensive view of haemodynamic pathophysiology; including pre-load, contractility, and afterload. Specifically, volume status could be estimated using mean systemic filling pressure (MSFP), the pressure to which all intravascular pressures equilibrate during asystole. Using the OD, MSFP could be readily estimated by simultaneous measurements of aortic blood flow and arterial pressure with sequential manoeuvres of increasing airway pressure. This would result in subsequent reductions in cardiac output and arterial pressure and would allow for a linear extrapolation of a static MSFP value to a "zero flow" state. In addition, we also demonstrate that EF is proportional to mean blood flow velocity measured in the descending thoracic aorta with the OD. Furthermore, OD-derived indexes of blood flow velocity and acceleration, as well as force and kinetic energy, can be derived and used for continuous assessment of cardiac contractility at the bedside. Using OD-derived parameters, the different components of afterload: inertia, resistance and elastance, could also be individually determined. The integration of these additional haemodynamic parameters could assist the clinician in optimising and individualising haemodynamic performance in unstable patients.

Journal of Clinical Monitoring and Computing 2016 end of year summary: cardiovascular and hemodynamic monitoring.

The assessment and optimization of cardiovascular and hemodynamic variables is a mainstay of patient management in the care for critically ill patients in the intensive care unit (ICU) or the operating room (OR). It is, therefore, of outstanding importance to meticulously validate technologies for hemodynamic monitoring and to study their applicability in clinical practice and, finally, their impact on treatment decisions and on patient outcome. In this regard, the Journal of Clinical Monitoring and Computing (JCMC) is an ideal platform for publishing research in the field of cardiovascular and hemodynamic monitoring. In this review, we highlight papers published last year in the JCMC in order to summarize and discuss recent developments in this research area.

Effects of acute hemorrhage on intrapulmonary shunt in a pig model of acute respiratory distress-like syndrome.

BACKGROUND: In acute respiratory distress syndrome (ARDS), gas exchange and respiratory system mechanics (compliance) are severely impaired. Besides ventilatory parameters, the degree of respiratory abnormality can be influenced by the circulatory state. This study investigated the influence of acute hypovolemia on the respiratory system. METHODS: We performed a secondary analysis of a previous study including 8 pigs with ARDS-like syndrome induced by lung lavage and surfactant depletion method (ARDS group) and 10 mechanically ventilated pigs with no intervention (CTRL group). Animals of both groups were subjected to hemorrhage and retransfusion successively. We reanalyzed the effect of acute blood volume variations on intrapulmonary shunt (shunt), arterial oxygenation (PaO2:FiO2), global oxygen delivery (DO2) and respiratory system compliance (Crs). RESULTS: In the ARDS group, after hemorrhage, shunt decreased (-28 +/- 3.5 % (p < 0.001)), respiratory system compliance (Crs) increased (+5.1 +/- 1.0 ml/cm H2O (p < 0.001)) moreover, there was a concurrent increase in PaO2:FiO2 (+113 +/- 19.1 mmHg; p < 0.001) but this did not prevent a reduction in DO2 (-317 +/- 49.8 ml/min; p < 0.001). Following retransfusion, shunt and Crs return towards pre-hemorrhage values. Similar changes, but of smaller magnitude were observed in the CTRL group, except that no significant changes in oxygenation occurred. CONCLUSIONS: The present analysis suggests that an acute decrease in blood volume results in a decrease in shunt with a parallel improvement in arterial oxygenation and an increase in Crs during ARDS-like syndrome. Our results strengthen the importance to integrate the circulatory condition in the analysis of the state of the respiratory system. However, the translation of this physiological model in a clinical perspective is not straightforward because our model of acute and severe hemorrhage is not strictly equivalent to a progressive hypovolemia, as could be obtained in ICU by diuretic. Furthermore, the present model does not consider the impact of blood loss induced decrease of DO2 on other vital organs function. TRIAL REGISTRATION: 'Not applicable'.