High flow nasal oxygen therapy to avoid invasive mechanical ventilation in SARS-CoV-2 pneumonia: a retrospective study.

BACKGROUND: The efficacy of high flow nasal canula oxygen therapy (HFNO) to prevent invasive mechanical ventilation (IMV) is not well established in severe coronavirus disease 2019 (COVID-19). The aim of this study was to compare the risk of IMV between two strategies of oxygenation (conventional oxygenation and HFNO) in critically ill COVID 19 patients. METHODS: This was a bicenter retrospective study which took place in two intensive care units (ICU) of tertiary hospitals in the Paris region from March 11, to May 3, 2020. We enrolled consecutive patients hospitalized for COVID-19 and acute respiratory failure (ARF) who did not receive IMV at ICU admission. The primary outcome was the rate of IMV after ICU admission. Secondary outcomes were death at day 28 and day 60, length of ICU stay and ventilator-free days at day 28. Data from the HFNO group were compared with those from the standard oxygen therapy (SOT) group using weighted propensity score. RESULTS: Among 138 patients who met the inclusion criteria, 62 (45%) were treated with SOT alone, and 76 (55%) with HFNO. In HFNO group, 39/76 (51%) patients received IMV and 46/62 (74%) in SOT group (OR 0.37 [95% CI, 0.18-0.76] p = 0.007). After weighted propensity score, HFNO was still associated with a lower rate of IMV (OR 0.31 [95% CI, 0.14-0.66] p = 0.002). Length of ICU stay and mortality at day 28 and day 60 did not significantly differ between HFNO and SOT groups after weighted propensity score. Ventilator-free days at days 28 was higher in HNFO group (21 days vs 10 days, p = 0.005). In the HFNO group, predictive factors associated with IMV were SAPS2 score (OR 1.13 [95%CI, 1.06-1.20] p = 0.0002) and ROX index > 4.88 (OR 0.23 [95%CI, 0.008-0.64] p = 0.006). CONCLUSIONS: High flow nasal canula oxygen for ARF due to COVID-19 is associated with a lower rate of invasive mechanical ventilation.

Early prediction of Candida glabrata fungemia in nonneutropenic critically ill patients.

OBJECTIVE: Candida species represent the fourth cause of nosocomial bloodstream infections worldwide. Because Candida glabrata has become the second most frequently identified yeast and because the rate of fluconazole-resistant C. glabrata strains reaches 10% to 15%, initial antifungal therapy based on fluconazole in nonneutropenic hemodynamically stable patients, as recommended by current guidelines, may be an ineffective option. Our aim was to determine easy-to-identify risk factors for C. glabrata fungemia likely to guide and improve initial antifungal therapy. DESIGN: Prospective multicenter cohort study. SETTING: Five French intensive care units. PATIENTS: Consecutive nonneutropenic patients without known Candida colonization who had blood culture-confirmed fungemia over a 4-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 8206 patients were screened. One hundred fifty-four patients with blood culture-confirmed fungemia constituted the cohort, of whom 48 had C. glabrata fungemia and 106 had nonglabrata fungemia. Patients' baseline characteristics and in-intensive care unit events potentially related to C. glabrata fungemia were systematically recorded. Compared with patients with nonglabrata fungemia, patients with C. glabrata fungemia were older and more severely ill, had received more antibiotics, and were more likely to have undergone surgery. The stepwise logistic regression analysis identified six independent risk factors for C. glabrata fungemia: age >60 yrs, recent abdominal surgery, interval from intensive care unit admission to first positive blood culture

Are daily routine chest radiographs useful in critically ill, mechanically ventilated patients? A randomized study.

OBJECTIVE: Whether chest radiographs (CXRs) in mechanically ventilated patients should be routinely obtained or only when an abnormality is anticipated remains debated. We aimed to compare the diagnostic, therapeutic and outcome efficacy of a restrictive prescription of CXRs with that of a routine prescription, focusing on delayed diagnoses and treatments potentially related to the restrictive prescription. DESIGN: Randomized controlled trial. SETTING: Intensive care unit of the Avicenne Teaching Hospital, Bobigny, France. PATIENTS AND PARTICIPANTS: All consecutive patients mechanically ventilated for > or = 48h between January and June 2006. INTERVENTIONS: Patients were randomly assigned to have daily routine CXRs (routine prescription group) or clinically indicated CXRs (restrictive prescription group). MEASUREMENTS AND RESULTS: For each CXR, a questionnaire was completed addressing the reason for the CXR, the new findings, and any subsequent therapeutic intervention. The endpoints were the rates of new findings, the rates of new findings that prompted therapeutic intervention, the rate of delayed diagnoses, and mortality. Eighty-four patients were included in the routine prescription group and 81 in the restrictive prescription group. The rates of new findings and the rates of new findings that prompted therapeutic intervention in the restrictive prescription group and in the routine prescription group were 66% vs. 7.2% (p < 0.0001), and 56.4% vs. 5.5% (p < 0.0001) respectively. The rate of delayed diagnoses in the restrictive prescription group was 0.7%. Mortality was similar. CONCLUSIONS: Restrictive use of CXRs in mechanically ventilated patients was associated with better diagnostic and therapeutic efficacies without impairing outcome.

Norepinephrine weaning in septic shock patients by closed loop control based on fuzzy logic.

INTRODUCTION: The rate of weaning of vasopressors drugs is usually an empirical choice made by the treating in critically ill patients. We applied fuzzy logic principles to modify intravenous norepinephrine (noradrenaline) infusion rates during norepinephrine infusion in septic patients in order to reduce the duration of shock. METHODS: Septic patients were randomly assigned to norepinephrine infused either at the clinician's discretion (control group) or under closed-loop control based on fuzzy logic (fuzzy group). The infusion rate changed automatically after analysis of mean arterial pressure in the fuzzy group. The primary end-point was time to cessation of norepinephrine. The secondary end-points were 28-day survival, total amount of norepinephine infused and duration of mechanical ventilation. RESULTS: Nineteen patients were randomly assigned to fuzzy group and 20 to control group. Weaning of norepinephrine was achieved in 18 of the 20 control patients and in all 19 fuzzy group patients. Median (interquartile range) duration of shock was significantly shorter in the fuzzy group than in the control group (28.5 [20.5 to 42] hours versus 57.5 [43.7 to 117.5] hours; P < 0.0001). There was no significant difference in duration of mechanical ventilation or survival at 28 days between the two groups. The median (interquartile range) total amount of norepinephrine infused during shock was significantly lower in the fuzzy group than in the control group (0.6 [0.2 to 1.0] microg/kg versus 1.4 [0.6 to 2.7] microg/kg; P < 0.01). CONCLUSIONS: Our study has shown a reduction in norepinephrine weaning duration in septic patients enrolled in the fuzzy group. We attribute this reduction to fuzzy control of norepinephrine infusion. TRIAL REGISTRATION: Trial registration: Clinicaltrials.gov NCT00763906.

Agreement between quantitative cultures of postintubation tracheal aspiration and plugged telescoping catheter, protected specimen brush, or BAL for the diagnosis of nosocomial pneumonia.

BACKGROUND: The diagnosis of ventilator-associated pneumonia relies on protected specimen brush (PSB), BAL, and plugged telescoping catheter (PTC) procedures. In the particular setting of nosocomial pneumonia (NP) occurring in non-mechanically ventilated patients, no consensus exists on their use. When mechanical ventilation (MV) becomes mandatory, postintubation tracheal aspiration (PITA) could be a simple, fast, and cheap diagnostic tool. Our aim was to compare the diagnostic accuracy of PITA to that of PSB, BAL, or PTC in patients requiring MV for suspected NP. METHODS: Patients with a prior hospital stay of > or = 48 h who required MV for suspicion of NP were prospectively enrolled in the study. PITA was performed by sterile suction. Within 2 h, pulmonary samples were obtained by PSB, BAL, or blinded PTC, which are referred to hereafter as "reference methods" (RMs). The definite diagnosis of NP was made using a composite item of clinical, radiologic, and bacteriologic (ie, blood or pleural fluid cultures) patterns. The agreement between the quantitative microbiological results obtained with PITA and those of the RMs was assessed by the kappa-statistic. The sensitivity, specificity, and positive and negative likelihood ratios of PITA and RMs were calculated taking the definite diagnosis of NP as the reference. RESULTS: There were 44 cases (63.8%) of confirmed NP. The kappa-statistic was 0.71. The sensitivity, specificity, and positive and negative likelihood ratios were 77%, 84%, 4.80, and 0.27, respectively, for PITA, and 75%, 88%, 6.25, and 0.28, respectively, for RMs. CONCLUSIONS: PITA may be a reliable alternative to RMs in the particular setting of NP in newly mechanically ventilated patients.

Differential diagnostic value of procalcitonin in surgical and medical patients with septic shock.

OBJECTIVE: To assess whether different diagnostic and prognostic cutoff values of procalcitonin should be considered in surgical and in medical patients with septic shock. DESIGN: Prospective observational study. SETTING: Intensive care unit of the Avicenne teaching hospital, France. PATIENTS: All patients with septic shock or noninfectious systemic inflammatory response syndrome within 48 hrs after admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were allocated to one of the following groups: group 1 (surgical patients with septic shock), group 2 (surgical patients with noninfectious systemic inflammatory response syndrome), group 3 (medical patients with septic shock), and group 4 (medical patients with noninfectious systemic inflammatory response syndrome). Procalcitonin at study entry was compared between group 1 and group 2 and between group 3 and group 4 to determine the diagnostic cutoff value in surgical and in medical patients, respectively. Procalcitonin was compared between survivors and nonsurvivors from group 1 and group 3 to determine its prognostic cutoff value. One hundred forty-three patients were included: 31 in group 1, 36 in group 2, 36 in group 3, and 40 in group 4. Median procalcitonin levels (ng/mL [interquartile range]) were higher in group 1 than in group 3 (34.00 [7.10-76.00] vs. 8.40 [3.63-24.70], p = .01). In surgical patients, the best diagnostic cutoff value was 9.70 ng/mL, with 91.7% sensitivity and 74.2% specificity. In medical patients, the best diagnostic cutoff value was 1.00 ng/mL, with 80% sensitivity and 94% specificity. Procalcitonin was a reliable early prognostic marker in medical but not in surgical patients with septic shock. A cutoff value of 6.00 ng/mL had 76% sensitivity and 72.7% specificity for separating survivors from nonsurvivors. CONCLUSIONS: The diagnostic cutoff value of procalcitonin was higher in surgical than in medical patients. Early procalcitonin was of prognostic interest in medical patients.

Predictors of intensive care unit refusal in French intensive care units: a multiple-center study.

OBJECTIVE: To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. DESIGN: Observational, prospective, multiple-center study. SETTING: Four university hospitals and seven primary-care hospitals in France. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. CONCLUSIONS: ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.

Diagnostic and prognostic value of procalcitonin in patients with septic shock.

OBJECTIVE: To determine whether procalcitonin is a reliable diagnostic and prognostic marker in septic shock compared with nonseptic shock. DESIGN: Prospective controlled trial. SETTING: Intensive care unit of the Avicenne Teaching Hospital, Bobigny, France. PATIENTS: All patients admitted to our intensive care unit over a 12-month period with clinical evidence of shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Echocardiography or pulmonary artery flotation catheter measurements were used to assess hemodynamics, and multiple specimens were obtained for microbiological studies. Standard criteria were used to diagnose septic shock. Serum concentrations of procalcitonin, C-reactive protein, and lactate were determined on the day of shock onset (day 1) and on days 3, 7, and 10. Seventy-five patients were included, 62 in the septic shock group and 13 in the cardiogenic shock group. Serum procalcitonin on day 1 was significantly higher in patients with than without septic shock (median, 14 [0.3-767] ng/mL vs. 1 [0.5-36] ng/mL, p < .01). A cutoff value of 1 ng/mL had 95% sensitivity and 54% specificity for separating patients with and without sepsis. C-reactive protein failed to discriminate between these two groups. Among patients with sepsis, procalcitonin concentrations were significantly higher in those who died than in the survivors, at all four measurement time points (median, 16 [0.15-767] ng/mL vs. 6 [0.2-123] ng/mL, p = .045 on day 1; 6.5 [0.3-135] ng/mL vs. 1.05 [0.11-53] ng/mL, p = .02 on day 10). A cutoff value of 6 ng/mL on day 1 separated patients who died from those who survived with 87.5% sensitivity and 45% specificity. C-reactive protein was not helpful for predicting mortality. Serum lactate was a nonspecific prognostic marker. CONCLUSIONS: These data indicate that procalcitonin may be a valuable early diagnostic and prognostic marker in patients with septic shock.