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.

An underrecognized source of organ donors: patients with brain death after successfully resuscitated cardiac arrest.

OBJECTIVE: To identify predictors of brain death after successful resuscitation of out-of-hospital cardiac arrest (OHCA), with the goal of improving the detection of brain death, and to evaluate outcomes of solid organs harvested from these patients. DESIGN AND SETTING: Prospective observational cohort study in a medical and surgical unit of a nonuniversity hospital. PATIENTS: Patients with successfully resuscitated OHCA were prospectively included in a database over a 7-year period. We looked for early predictors of brain death and compared outcomes of organ transplants from these patients to those from patients with brain death due to head injury or stroke. RESULTS: Over the 7-year period 246 patients were included. No early predictors of brain death were found. Of the 40 patients (16%) who met criteria for brain death, after a median ICU stay of 2.5 days (IQR 2.0-4.2), 19 donated 52 solid organs (29 kidneys, 14 livers, 7 hearts, and 2 lungs). Outcomes of kidneys and livers did not differ between donors with and without resuscitated cardiac arrest. CONCLUSIONS: Brain death may occur in about one-sixth of patients after successfully resuscitated OHCA, creating opportunities for organ donation.

Incidence and risk factors of immune reconstitution inflammatory syndrome complicating HIV-associated cryptococcosis in France.

BACKGROUND: Immune reconstitution inflammatory syndrome (IRIS) in association with cryptococcosis has been anecdotically reported following administration of highly active antiretroviral therapy (HAART). OBJECTIVE: To analyse the incidence and risk factors for IRIS-associated cryptococcosis among HIV-infected patients. DESIGN: Retrospective multicentre study between 1996 and 2000 through the French Cryptococcosis Database. METHODS: Subsequent occurrence of IRIS examined in 120 HIV-infected adult patients treated with HAART and experiencing a first episode of culture-confirmed cryptococcosis. RESULTS: Ten patients developed IRIS during the study period, giving an incidence of 10/239, or 4.2/100 person-years [95% confidence interval (CI), 2.2-7.8]. IRIS consisted of acute symptoms consistent with inflammation occurring within a median of 8 months (range, 2-37) after the diagnosis of cryptococcosis in the context of negative cultures and immunological and/or virological response to HAART. Radiology and histopathology detected features compatible with inflammation. Symptom severity required transfer into intensive care units for three patients and use of anti-inflammatory drugs for four. Three patients with evolutive IRIS died. Compared with patients without IRIS for whom complete clinical and microbiological information were available at baseline, previously unknown HIV infection [odds ratio (OR), 4.8; 95% CI, 1.0-21.7], CD4 cell count < 7 x 10 cells/l (OR, 4.0; 95% CI, 0.9-17.2), fungaemia (OR, 6.1; 95% CI, 1.1-35.2) and HAART initiation within 2 months of cryptococcosis diagnosis (OR, 5.50; 95% CI, 1.0-29.6) were independently associated with the risk of subsequent IRIS. CONCLUSIONS: IRIS-related cryptococcosis was observed more frequently in severely immunocompromised patients with disseminated infection and HAART initiation soon after the diagnosis.

DNAemia detection by multiplex PCR and biomarkers for infection in systemic inflammatory response syndrome patients.

Fast and reliable assays to precisely define the nature of the infectious agents causing sepsis are eagerly anticipated. New molecular biology techniques are now available to define the presence of bacterial or fungal DNA within the bloodstream of sepsis patients. We have used a new technique (VYOO®) that allows the enrichment of microbial DNA before a multiplex polymerase chain reaction (PCR) for pathogen detection provided by SIRS-Lab (Jena, Germany). We analyzed 72 sepsis patients and 14 non-infectious systemic inflammatory response syndrome (SIRS) patients. Among the sepsis patients, 20 had a positive blood culture and 35 had a positive microbiology in other biological samples. Of these, 51.4% were positive using the VYOO® test. Among the sepsis patients with a negative microbiology and the non-infectious SIRS, 29.4% and 14.2% were positive with the VYOO® test, respectively. The concordance in bacterial identification between microbiology and the VYOO® test was 46.2%. This study demonstrates that these new technologies offer great hopes, but improvements are still needed.

Delayed relapse of Churg-Strauss syndrome manifesting as colon ulcers with mucosal granulomas: 3 cases.

Churg-Strauss syndrome (CSS) is characterized by small vessel vasculitis and extravascular granulomas. The American College of Rheumatology classification criteria for CSS include asthma, eosinophili, and clinical manifestation of vasculitis. Gastrointestinal (GI) manifestations occur in 30% of patients, but are inaugural in only 16%. They denote vasculitis of the stomach and small bowel wall, and consist in protean, nonspecific pain. GI involvement is of adverse prognostic significance in CSS. Ulcer formation in the GI tract mucosa is a rarer manifestation, usually discovered upon laparotomy or autopsy. We describe 3 new cases of colonic ulcers in CSS. Unusual features were diagnosis of the ulcers during a delayed relapse and presence of eosinophilic granulomas within the mucosa.

Differential diffusions of indinavir and lopinavir in genital secretions of human immunodeficiency virus-infected women.

Plasma and cervicovaginal secretion (CVS) samples were collected from 19 human immunodeficiency virus type 1-infected women on lopinavir- or indinavir-containing regimens. Lopinavir and indinavir were detectable in 29 and 93% of CVS samples, respectively, a finding that may be ascribed to these drugs' differences in protein binding and pK(a). The relationship between lopinavir and indinavir pharmacodynamics and viral evolution in the female genital tract should be assessed over time.