An outbreak of Pneumocytis jirovecii pneumonia among liver transplant recipients.

BACKGROUND: An outbreak of Pneumocystis pneumonia (PCP) in liver transplant recipients occurred between 2009 and 2011 at the Beaujon University Hospital just after immediate-release tacrolimus was replaced by extended-release tacrolimus. We conducted a retrospective study to analyze the transmission mode of Pneumocystis, the role of the change in the immunosuppressive regimen, and the factors associated with PCP. PATIENTS AND METHODS: To analyze transmission, we built a transmission map. Two control groups were built. First, to assess the role of the change from tacIR to tacER, cases were matched to controls transplanted before 2009 (tacIR control group). Tacrolimus trough concentrations were compared between the 2 groups. Then, to assess factors associated with PCP, each PCP case was matched to 2 control patients: the one transplanted just before and the one just after (PCPAsFact control group). No PCP prophylaxis was given to any patient. RESULTS: Fifteen cases of PCP were recorded. A contact between a case and a patient who developed PCP afterward was identified in 4 occasions. The comparison of tacrolimus trough concentrations did not conclude to a difference in the exposure to the drug. Lymphopenia was the only factor independently associated with the occurrence of PCP (odds ratio 0.78, 95% confidence interval 0.61-0.99, P = .04). CONCLUSION: Our results suggest that patient-to-patient transmission was not the main mode of transmission of PCP. We found no evidence that the switch from tacIR to tacER led to an overexposure to tacrolimus. Our results suggest the possibility of targeted prophylaxis in immunosuppressed liver transplant recipients.

Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia.

OBJECTIVES: Tracheal intubation of ICU patients is frequently associated with severe hypoxemia. Although noninvasive ventilation reduces desaturation during intubation of severely hypoxemic patients, it does not allow for per-procedure oxygenation and has not been evaluated in mild-to-moderate hypoxemic patients for whom high-flow nasal cannula oxygen may be an alternative. We sought to compare pre- and per-procedure oxygenation with either a nonrebreathing bag reservoir facemask or a high-flow nasal cannula oxygen during tracheal intubation of ICU patients. DESIGN: Prospective quasi-experimental before-after study (ClinicalTrials.gov: NCT01699880). SETTING: University hospital medico-surgical ICU. PATIENTS: All adult patients requiring tracheal intubation in the ICU were eligible. INTERVENTIONS: In the control (before) period, preoxygenation was performed with a nonrebreathing bag reservoir facemask and in the change of practice (after) period, with high-flow nasal cannula oxygen. MEASUREMENTS AND MAIN RESULTS: Primary outcome was median lowest SpO2 during intubation, and secondary outcomes were SpO2 after preoxygenation and number of patients with saturation less than 80%. One hundred one patients were included. Median lowest SpO2 during intubation were 94% (83-98.5) with the nonrebreathing bag reservoir facemask versus 100% (95-100) with high-flow nasal cannula oxygen (p < 0.0001). SpO2 values at the end of preoxygenation were higher with high-flow nasal cannula oxygen than with nonrebreathing bag reservoir facemask and were correlated with the lowest SpO2 reached during the intubation procedure (r = 0.38, p < 0.0001). Patients in the nonrebreathing bag reservoir facemask group experienced more episodes of severe hypoxemia (2% vs 14%, p = 0.03). In the multivariate analysis, preoxygenation with high-flow nasal cannula oxygen was an independent protective factor of the occurrence of severe hypoxemia (odds ratio, 0.146; 95% CI, 0.01-0.90; p = 0.037). CONCLUSIONS: High-flow nasal cannula oxygen significantly improved preoxygenation and reduced prevalence of severe hypoxemia compared with nonrebreathing bag reservoir facemask. Its use could improve patient safety during intubation.

Variation of the SOFA score and mortality in patients with severe burns: A cohort study.

Multiple organ failure (MOF) is the leading cause of death in patients with burns requiring ICU admission. Quantifying the evolution of MOF, with the SOFA score, over the first few days after a severe burn may provide useful prognostic information. This retrospective cohort study aimed at evaluating the association between the evolution of the SOFA score between day 0 and day 3 and in-hospital mortality. All patients admitted for severe burns at the burn ICU of the Tours University Hospital between 2017 and 2020 and who stayed 3 days or more were included. Severe burns included: total body surface area burned (TBSA) ≥ 20 % or burns of any surface associated with one or more of the following items: (1) organ failure, (2) clinically significant smoke inhalation and/or cyanide poisoning, (3) severe preexisting comorbidities, (4) complex and specialized burn wound care. DeltaSOFA was defined as day 3 minus day 0 SOFA. One hundred and thirty-six patients were included. Median age was 52 years (38-70), median TBSA burned was 24 % (20-38), median day 0 SOFA was 2 (0-4) and median day 3 SOFA was 1 (0-5). In-hospital mortality was 10 %. There was a significant association between deltaSOFA and mortality that persisted after adjustment for age and TBSA (HR 1.37, 95 %CI 1.09-1.72, p < 0.01). Area under the receiver operating characteristics curve for the prediction of mortality by day 0 SOFA and deltaSOFA were 0.79 (95 %CI 0.69-0.89) and 0.83 (95 %CI 0.70-0.95) respectively. After exclusion of patients with TBSA burned< 15 %, deltaSOFA remained independently associated with mortality (HR 1.42 95 %CI 1.09-1.85, p < 0.01). In addition, SOFA variations allowed the identification of subgroups of patients with either very low or very high mortality. In patients with severe burns, SOFA score evolution between day 0 and day 3 may be useful for individualized medical and ethical decisions. Further multicenter studies are required to corroborate the present results.

Can we improve transthoracic echocardiography training in non-cardiologist residents? Experience of two training programs in the intensive care unit.

BACKGROUND: To evaluate the diagnostic performances of two training programs for residents with no prior ultrasound experience to reach competences in extended basic critical care transthoracic echocardiography (CCE) including Doppler capabilities. METHODS: This is a prospective observational study in two intensive care units of teaching hospitals. Group I (five residents) completed a short training program (4-h theory; 3-h practical); group II (six residents) completed a longer training program (6-h theory; 12-h practical). The residents and an expert examined all patients who required a transthoracic echocardiography. Their agreement studied by Cohen's κ coefficient, concordance coefficient correlation (CCC) and Bland-Altman plots was used as an indicator of program effectiveness. RESULTS: Group I performed 136 CCEs (mean/resident 27; range 22-32; 65 in ventilated patients) in 115 patients (62 men; 64 ± 18 years; Simplified Acute Physiologic Score [SAPS] II 37 ± 18). Group II performed 158 CCEs (mean/resident 26; range 21-31; 65 in ventilated patients) in 108 patients (64 men; 58 ± 17 years; SAPS II 42 ± 22). Both groups adequately assessed left ventricular (LV) systolic function (κ 0.75, 95 % confidence interval [CI] 0.64-0.86; κ 0.77, 95 % CI 0.66-0.88, respectively) and pericardial effusion (κ 0.83, 95 % CI 0.67-0.99; κ 0.76, 95 % CI 0.60-0.93, respectively). Group II appraised severe right ventricular dilatation and significant left-sided valve disease with good to very good agreement (κ 0.80, 95 % CI 0.56-0.96; κ 0.79, 95 % CI 0.66-0.93, respectively). Regarding left ventricular ejection fraction, E/A ratio, E/e' ratio and aortic peak velocity assessed by group II, CCCs were all >0.70 and the bias (mean difference) ±SD on Bland-Altman analysis was 1.3 ± 8.8 %, 0 ± 0.3, 0.4 ± 2.2 and 0.1 ± 0.4 m/s, respectively. Detection of paradoxical septum (κ 0.65, 95 % CI 0.37-0.93), of heterogeneous LV contraction (κ 0.49, 95 % CI 0.33-0.65) and of respiratory variation of the inferior vena cava (κ 0.27, 95 % CI 0.09-0.45), as well as stroke volume measurement (CCC 0.65, 95 % CI 0.54-0.74; bias ± SD -1.4 ± 4.7 cm), was appraised by group II with moderate agreement requiring probably more comprehensive training. CONCLUSIONS: Although a training program blending 6-h theory and 12-h practical may be adapted to achieve some essential competences, it seems to be insufficiently to perform a complete extended basic critical care transthoracic echocardiography including Doppler capabilities.

Use of High-Flow Nasal Cannula Oxygen Therapy in Subjects With ARDS: A 1-Year Observational Study.

BACKGROUND: Beneficial effects of high-flow nasal cannula (HFNC) oxygen on oxygenation and respiratory parameters have been reported in a small number of subjects with acute respiratory failure (ARF). We aimed to evaluate its effect in subjects with ARDS. METHODS: This was an observational single-center study. Prospectively obtained data were retrospectively analyzed. All patients admitted over 1 y to a university hospital medicosurgical ICU were included. Classification was according to the highest ventilatory support required. HFNC indications were reviewed, and demographics, clinical characteristics, and course of subjects with ARDS according to intubation need were compared. RESULTS: Of 607 subjects admitted, 560 required ventilatory or oxygen support, among whom 180 received noninvasive ventilatory support. HFNC was used in 87 subjects and as first-line treatment in 51 subjects (29% of first-line noninvasively treated subjects), 45 of which had ARDS (PaO2 /FIO2 of 137 mm Hg; 22 men, 57.9 y of age). Pneumonia accounted for 82% of ARDS causes. The intubation rate in these subjects was 40%. Higher Simplified Acute Physiology Score II (SAPS II; 46 vs 29, P=.001), occurrence of additional organ failure (76% vs 26%, P=.002), mainly hemodynamic (50% vs 7%, P=.001) or neurological (22% vs 0, P=.01), and trends toward lower PaO2 /FIO2 and higher breathing frequency after HFNC initiation were evidenced in subjects who failed HFNC. Higher SAPS II scores were associated with HFNC failure in multivariate analysis. CONCLUSIONS: In daily care, over one fourth of subjects requiring noninvasive ventilatory support were treated via HFNC, with a high success rate in subjects with severe ARDS. We conclude that HFNC may be considered as first-line therapy in ARF, including patients with ARDS.

Use of desmopressin acetate in severe hyponatremia in the intensive care unit.

BACKGROUND AND OBJECTIVES: Excessive correction of chronic and profound hyponatremia may result in central pontine myelinolysis and cause permanent brain damage. In the case of foreseeable or established hyponatremia overcorrection, slowing down the correction rate of sodium plasma levels (PNa) or reinducing mild hyponatremia may prevent this neurologic complication. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective and observational study was performed with 20 consecutive patients admitted to two intensive care units for severe hyponatremia, defined by PNa <120 mmol/L and/or neurologic complications ascribable to hyponatremia and subsequently treated by desmopressin acetate (DDAVP) during correction of hyponatremia when the rate of correction was overtly or predictably excessive. The primary endpoint was the effectiveness of DDAVP on PNa control. RESULTS: DDAVP dramatically decreased the rate of PNa correction (median 0.81 mmol/L per hour [interquartile range, 0.46, 1.48] versus -0.02 mmol/L per hour [-0.16, 0.22] before and after DDAVP, respectively; P<0.001) along with a concurrent decrease in urine output (650 ml/h [214, 1200] versus 93.5 ml/h [43, 143]; P=0.003), and a rise in urine osmolarity (86 mmol/L [66, 180] versus 209 mmol/L [149, 318]; P=0.002). The maximal magnitude of PNa variations was also markedly reduced after DDAVP administration (11.5 mmol/L [8.25, 14.5] versus 5 mmol/L [4, 6.75]; P<0.001). No patient developed seizures after DDAVP or after subsequent relowering of PNa that occurred in 11 patients. CONCLUSIONS: Desmopressin acetate is effective in curbing the rise of PNa in patients admitted in the intensive care unit for severe hyponatremia, when the initial rate of correction is excessive.