The utility of the respiratory rate-oxygenation index as a predictor of treatment response in dogs receiving high-flow nasal cannula oxygen therapy.

Objective: This study aims to evaluate the respiratory rate-oxygenation index (ROX) and the ratio of pulse oximetry saturation (SpO2) to the fraction of inspired oxygen (FiO2) (SpO2/FiO2, [SF]) to determine whether these indices are predictive of outcome in dogs receiving high-flow nasal cannula oxygen therapy (HFNOT). Design: This is a prospective observational study. Setting: This study was carried out at two university teaching hospitals. Animals: In total, 88 dogs treated with HFNOT for hypoxemic respiratory failure due to various pulmonary diseases were selected. Measurements and main results: The ROX index was defined as the SF divided by the respiratory rate (RR). ROX and SF were calculated at baseline and for each hour of HFNOT. The overall success rate of HFNOT was 38% (N = 33/88). Variables predicting HFNOT success were determined using logistic regression, and the predictive power of each variable was assessed using the area under the receiver operating curve (AUC). ROX and SF were adequately predictive of HFNOT success when averaged over 0-16 h of treatment, with similar AUCs of 0.72 (95% confidence interval [CI] 0.60-0.83) and 0.77 (95% CI 0.66-0.87), respectively (p < 0.05). SF showed acceptable discriminatory power in predicting HFNOT outcome at 7 h, with an AUC of 0.77 (95% CI 0.61-0.93, p = 0.013), and the optimal cutoff for predicting HFNC failure at 7 h was SF ≤ 191 (sensitivity 83% and specificity 76%). Conclusion: These indices were easily obtained in dogs undergoing HFNOT. The results suggest that ROX and SF may have clinical utility in predicting the outcomes of dogs on HFNOT. Future studies are warranted to confirm these findings in a larger number of dogs in specific disease populations.

[Post-traumatic growth of critical care nursing teams after the Covid-19 pandemic]. / Croissance post-traumatique des équipes soignantes de soins critiques après la pandémie de Covid-19.

As the negative psychological impact of Covid-19 is no longer in doubt, the aim of the study presented here was to quantify the post-traumatic growth (PTC) of caregivers working in critical care. To this end, a paper questionnaire was distributed in the critical care department of the Lyon-Sud hospital. Among the care team, 67% had developed PTC, showing that despite the difficulties experienced during the trauma, the team had managed to grow from this crisis.

A multimodal tissue perfusion measurement approach for the evaluation of the effect of pimobendan, an inodilator, in a porcine sepsis model.

Sepsis is associated with hypoperfusion and organ failure. The aims of the study were: 1) to assess the effect of pimobendan on macrocirculation and perfusion and 2) to describe a multimodal approach to the assessment of perfusion in sepsis and compare the evolution of the perfusion parameters. Eighteen anaesthetized female piglets were equipped for macrocirculation monitoring. Sepsis was induced by an infusion of Pseudomonas aeruginosa. After the occurrence of hypotension, animals were resuscitated. Nine pigs received pimobendan at the start of resuscitation maneuvers, the others received saline. Tissue perfusion was assessed using temperature gradients measured with infrared thermography (TG = core temperature - tarsus temperature), urethral perfusion index (uPI) derived from photoplethysmography and sublingual microcirculation (Sidestream dark field imaging device): De Backer score (DBs), proportion of perfused vessels (PPV), microvascular flow index (MFI) and heterogeneity index (HI). Arterial lactate and ScvO2 were also measured. Pimobendan did not improve tissue perfusion nor macrocirculation. It did not allow a reduction in the amount of noradrenaline and fluids administered. Sepsis was associated with tissue perfusion disorders: there were a significant decrease in uPI, PPV and ScvO2 and a significant rise in TG. TG could significantly predict an increase in lactate. Resuscitation was associated with a significant increase in uPI, DBs, MFI, lactate and ScvO2. There were fair correlations between the different perfusion parameters. In this model, pimobendan did not show any benefit. The multimodal approach allowed the detection of tissue perfusion alteration but only temperature gradients predicted the increase in lactatemia.

Comparison of mortality and outcomes of four respiratory viruses in the intensive care unit: a multicenter retrospective study.

This retrospective study aimed to compare the mortality and burden of respiratory syncytial virus (RSV group), SARS-CoV-2 (COVID-19 group), non-H1N1 (Seasonal influenza group) and H1N1 influenza (H1N1 group) in adult patients admitted to intensive care unit (ICU) with respiratory failure. A total of 807 patients were included. Mortality was compared between the four following groups: RSV, COVID-19, seasonal influenza, and H1N1 groups. Patients in the RSV group had significantly more comorbidities than the other patients. At admission, patients in the COVID-19 group were significantly less severe than the others according to the simplified acute physiology score-2 (SAPS-II) and sepsis-related organ failure assessment (SOFA) scores. Using competing risk regression, COVID-19 (sHR = 1.61; 95% CI 1.10; 2.36) and H1N1 (sHR = 1.87; 95% CI 1.20; 2.93) were associated with a statistically significant higher mortality while seasonal influenza was not (sHR = 0.93; 95% CI 0.65; 1.31), when compared to RSV. Despite occurring in more severe patients, RSV and seasonal influenza group appear to be associated with a more favorable outcome than COVID-19 and H1N1 groups.

Occurrence of cardiovascular events in 168 cats with acute urinary tract obstruction.

Background: Cardiovascular dysfunction associated with acute kidney injury has been recently described in veterinary medicine, but limited information is available for cats with urinary tract obstruction (UTO). Objective: This retrospective study aimed to describe the type, frequency, timeline, and risk factors for cardiovascular events (CVEs) in cats treated for acute UTO. Animals and procedures: Medical records of cats admitted to the intensive care unit for either upper (ureteral: UUTO) or lower (urethral: LUTO) UTO from 2016 to 2021 were reviewed. Cardiovascular events were defined as development of arrhythmia, heart murmur or gallop sound, clinical signs consistent with fluid overload (CRFO), or decreased tissue perfusion (DTP). Results: One hundred and sixty-eight cats with UTO were recruited (56 with UUTO and 112 with LUTO). Cardiovascular events were reported in 61.9% of cases, including arrhythmia (33.6%), gallop rhythm (28.1%), heart murmur (15.3%), CRFO (14.4%), and DTP (8.6%). Potassium concentration, preexisting chronic kidney disease, and renal pelvic dilation at abdominal ultrasonography were associated with CVE occurrence in multivariate analysis. Conclusions: This study highlighted frequent CVEs in cats treated for UTO, with a potential strong impact on outcome. Therefore, cardiovascular parameters of cats with preexisting chronic kidney disease or those admitted with hyperkalemia or renal pelvic dilation should be closely monitored.

Survenue d'anomalies cardio-vasculaires chez 168 chats présentés pour obstruction du tractus urinaire. Contexte: Si des anomalies cardiovasculaires secondaires à une insuffisance rénale aigue ont été décrites récemment en médecine vétérinaire, ces données restent limitées concernant les obstructions du tractus urinaire (OTU) chez le chat. Objectif: Décrire le type, la fréquence, le délai d'apparition et les facteurs de risques d'anomalies cardio-vasculaires (ACV) chez des chats hospitalisés pour OTU aigue. Animaux et protocoles: Les dossiers médicaux des chats admis en unité de soins intensifs pour obstruction du tractus urinaire haut ( urétérales-OTUH) et bas (urétrales-OTUB) entre 2016 et 2021 ont été consultés. Les ACV retenus étaient des arythmies cardiaques, le développement de souffles cardiaques et de bruits de galop, les signes relatifs à une surcharge en fluide (SRSF) et de diminution de la perfusion tissulaire (SDPT). Résultats: Cent soixante-huit chats avec des OTU ont été recrutés (56 OTUH, 112 OTUB). Des ACV ont été observés dans 61,9 % des cas, incluant des arythmies (33,6 %), l'apparition de bruits de galop (28,1 %) et de souffles cardiaques (15,3 %), des SRSF (14,4 %) et des SDPT (8,6 %). La concentration plasmatique en potassium, la présence d'une MRC sous-jacente et d'une dilatation pyélique à l'échographie abdominale ont été associées à la présence d'ACV par l'analyse multivariée. Conclusions: Cette étude montre que les ACV surviennent fréquemment chez les chats présentés pour OTU, et suggère un impact sur la survie de ces animaux. Les animaux avec un historique de MRC, ceux présentés avec une hyperkaliémie et/ou avec une dilatation pyélique à l'échographie abdominale devraient être surveillés avec plus de précautions que les autres.(Traduit per les auteurs).

Occurrences of post-traumatic stress disorder, anxiety, depression, and burnout syndrome in ICU staff workers after two-year of the COVID-19 pandemic: the international PSY-CO in ICU study.

PURPOSE: The present study aimed at assessing the prevalences of post-traumatic stress disorder (PTSD) (main objective), anxiety, depression, and burnout syndrome (BOS) and their associated factors in intensive care unit (ICU) staff workers in the second year of the COVID-19 pandemic. MATERIALS AND METHODS: An international cross-sectional multicenter ICU-based online survey was carried out among the ICU staff workers in 20 ICUs across 3 continents. ICUs staff workers (both caregivers and non-caregivers) were invited to complete PCL-5, HADS, and MBI questionnaires for assessing PTSD, anxiety, depression, and the different components of BOS, respectively. A personal questionnaire was used to isolate independent associated factors with these disorders. RESULTS: PCL-5, HADS, and MBI questionnaires were completed by 585, 570, and 539 responders, respectively (525 completed all questionnaires). PTSD was diagnosed in 98/585 responders (16.8%). Changing familial environment, being a non-caregiver staff worker, having not being involved in a COVID-19 patient admission, having not been provided with COVID-19-related information were associated with PTSD. Anxiety was reported in 130/570 responders (22.8%). Working in a public hospital, being a woman, being financially impacted, being a non-clinical healthcare staff member, having no theoretical or practical training on individual preventive measures, and fear of managing COVID-19 patients were associated with anxiety. Depression was reported in 50/570 responders (8.8%). Comorbidity at risk of severe COVID-19, working in a public hospital, looking after a child, being a non-caregiver staff member, having no information, and a request for moving from the unit were associated with depression. Having received no information and no adequate training for COVID-19 patient management were associated with all 3 dimensions of BOS. CONCLUSION: The present study confirmed that ICU staff workers, whether they treated COVID-19 patients or not, have a substantial prevalence of psychological disorders.

Improved 30-Day Survival Estimation in ICU Patients: A Comparative Analysis of Different Approaches With Real-World Data.

OBJECTIVES: The objective of this study was to compare three different approaches for estimating 30-day survival in ICU studies, considering the issue of informative censoring that occurs when patients are lost to follow-up after discharge. DESIGN: A comparative analysis was conducted to evaluate the effect of different approaches on the estimation of 30-day survival. Three methods were compared: the classical approach using the Kaplan-Meier (KM) estimator and Cox regression modeling, the competing risk approach using the Fine and gray model, considering censoring as a competing event, and the logistic regression approach. SETTING: The study was conducted in a university ICU and data from patients admitted between 2010 and 2020 were included. Patient characteristics were collected from electronic records. PATIENTS: A total of 10,581 patients were included in the study. The true date of death for each patient, obtained from a national registry, allowed for an absence of censoring. INTERVENTIONS: All patients were censored at the time of discharge from the ICU, and the three different approaches were applied to estimate the mortality rate and the effects of covariates on mortality. Regression analyses were performed using five variables known to be associated with ICU mortality. MEASUREMENTS AND MAIN RESULTS: The 30-day survival rate for the included patients was found to be 80.5% (95% CI, 79.7-81.2%). The KM estimator severely underestimated the 30-day survival (50.6%; 95% CI, 48.0-53.4%), while the competing risk and logistic regression approaches provided similar results, only slightly overestimating the survival rate (84.5%; 95% CI, 83.8-85.2%). Regression analyses showed that the estimates were not systematically biased, with the Cox and logistic regression models exhibiting greater bias compared with the competing risk regression method. CONCLUSIONS: The competing risk approach provides more accurate estimates of 30-day survival and is less biased compared with the other methods evaluated.

Prognostic value of capillary refill time in adult patients: a systematic review with meta-analysis.

PURPOSE: Acute circulatory failure leads to tissue hypoperfusion. Capillary refill time (CRT) has been widely studied, but its predictive value remains debated. We conducted a meta-analysis to assess the ability of CRT to predict death or adverse events in a context at risk or confirmed acute circulatory failure in adults. METHOD: MEDLINE, EMBASE, and Google scholar databases were screened for relevant studies. The pooled area under the ROC curve (AUC ROC), sensitivity, specificity, threshold, and diagnostic odds ratio using a random-effects model were determined. The primary analysis was the ability of abnormal CRT to predict death in patients with acute circulatory failure. Secondary analysis included the ability of CRT to predict death or adverse events in patients at risk or with confirmed acute circulatory failure, the comparison with lactate, and the identification of explanatory factors associated with better accuracy. RESULTS: A total of 60,656 patients in 23 studies were included. Concerning the primary analysis, the pooled AUC ROC of 13 studies was 0.66 (95%CI [0.59; 0.76]), and pooled sensitivity was 54% (95%CI [43; 64]). The pooled specificity was 72% (95%CI [55; 84]). The pooled diagnostic odds ratio was 3.4 (95%CI [1.4; 8.3]). Concerning the secondary analysis, the pooled AUC ROC of 23 studies was 0.69 (95%CI [0.65; 0.74]). The prognostic value of CRT compared to lactate was not significantly different. High-quality CRT was associated with a greater accuracy. CONCLUSION: CRT poorly predicted death and adverse events in patients at risk or established acute circulatory failure. Its accuracy is greater when high-quality CRT measurement is performed.

Iron as an emerging therapeutic target in critically ill patients.

The multiple roles of iron in the body have been known for decades, particularly its involvement in iron overload diseases such as hemochromatosis. More recently, compelling evidence has emerged regarding the critical role of non-transferrin bound iron (NTBI), also known as catalytic iron, in the care of critically ill patients in intensive care units (ICUs). These trace amounts of iron constitute a small percentage of the serum iron, yet they are heavily implicated in the exacerbation of diseases, primarily by catalyzing the formation of reactive oxygen species, which promote oxidative stress. Additionally, catalytic iron activates macrophages and facilitates the growth of pathogens. This review aims to shed light on this underappreciated phenomenon and explore the various common sources of NTBI in ICU patients, which lead to transient iron dysregulation during acute phases of disease. Iron serves as the linchpin of a vicious cycle in many ICU pathologies that are often multifactorial. The clinical evidence showing its detrimental impact on patient outcomes will be outlined in the major ICU pathologies. Finally, different therapeutic strategies will be reviewed, including the targeting of proteins involved in iron metabolism, conventional chelation therapy, and the combination of renal replacement therapy with chelation therapy.

Use of high-flow oxygen therapy in a cat with cardiogenic pulmonary edema.

Case summary: A 7-month-old female spayed domestic shorthair cat was presented for respiratory distress due to cardiogenic pulmonary edema. Despite initial treatment and oxygen delivery in an oxygen tent, the cat still showed signs of severe respiratory effort and oxygen saturation measured via pulse oximetry was below 85%. Because the owners declined mechanical ventilation, the cat was transitioned to high-flow oxygen therapy (HFOT). HFOT allowed significant improvement of the respiration parameters within 15 mins without causing clinical complications. The cat was briefly anaesthetised for the placement of the nasal cannula on initiation of HFOT, and the interface was well tolerated thereafter. The cat was transitioned to an oxygen cage after 16 h, weaned from oxygen 4 h later and was discharged after 3 days of hospitalisation. Long-term follow-up showed no abnormalities, and the leading hypothesis was transient myocardial thickening. Relevance and novel information: The first use of HFOT in a dyspneic cat is described in this study. HFOT could be a life-saving option for cats with severe hypoxemia or do-not-intubate orders that fail to respond to conventional oxygen therapies.

Outcome and factors associated with mortality in patients receiving urgent chemotherapy in the ICU: A retrospective study.

PURPOSE: This study aimed to assess the outcome and factors associated with mortality in patients who received urgent chemotherapy (CT) in the intensive care unit (ICU) in Lyon, France. MATERIAL AND METHODS: A total of 147 adult patients diagnosed with cancer and requiring urgent CT during ICU stay between October 2014 and December 2019 were included in this retrospective study. RESULTS: Hematological cancer was found in 77% of patients, and acute respiratory failure was the leading cause of ICU admission (46.3%). The 6-month mortality rate was 69.4%; patients with solid cancer had a higher risk of mortality. Patients who died within 6 months had a poor performance score and a higher SOFA score at admission. The multivariate analysis showed that solid tumors, sepsis on the day of CT, and SOFA score on the day of CT were associated with 6-month mortality. Additionally, 95% of patients who survived the ICU resumed conventional CT, with a higher likelihood of resuming CT among those with hematological cancer. CONCLUSION: Urgent CT in the ICU is feasible in a specific subset of patients, mainly those with hematological cancer, with resumption of the curative treatment regimen after ICU discharge.

Use of 1,3-Beta-D-Glucan concentration in peritoneal fluid for the diagnosis of intra-abdominal Candidiasis in Critically-ill patients.

Intra-Abdominal Candidiasis (IAC) is frequent and associated with high mortality in intensive care unit (ICU) patients. Antifungal treatments may be overused due to a lack of diagnostic tools to rule out IAC. Serum 1,3-Beta-D-Glucan (BDG) concentrations are used to diagnose Candida infections, its concentration in peritoneal fluid (PF) may help to confirm or invalidate the diagnosis of IAC. We performed a non-interventional, prospective, multicenter study, at the Hospices Civils de Lyon, France, in seven ICU located in three different hospitals from December 2017 to June 2018. IAC was defined as the isolation of Candida in a sample collected from the intra-abdominal cavity under sterile conditions in patients displaying clinical evidence of intra-abdominal infection. Among the 113 included patients, 135 PF samples corresponding to 135 intra-abdominal infection episodes were collected and BDG concentrations were assessed. IAC accounted for 28 (20.7%) of the intra-abdominal infections. Antifungals were administered empirically to 70 (61.9%) patients; among them, 23 (32.9%) had an IAC. The median [IQR] BDG value was significantly higher in IAC (8100 [3000;15000] pg/mL) than in non-IAC samples (1961 [332;10650] pg/mL). BDG concentrations were higher in PF with Fecaloid aspect and in case of positive bacterial culture. For a BDG threshold of 125 pg/mL, the negative predictive value to assess IAC was 100%. In conclusion, low BDG PF concentrations could be used to rule out IAC. https://clinicaltrials.gov/ct2/show/NCT03469401.

Intra-Abdominal Candidiasis (IAC) is associated with a high mortality in Intensive Care Unit (ICU) patients. 1,3-Beta-D-Glucan (BDG), a component of Candida cell wall, was prospectively measured in peritoneal fluid from ICU patients Low peritoneal BDG concentrations may be used to rule out IAC.

Use of pupillometry for the evaluation of analgesia in dogs hospitalized in intensive care: A prospective study.

A prospective study was performed on hospitalized conscious dogs. The objectives were: 1) to evaluate the feasibility and reliability of portable infrared pupillometry using a measure of photo light reflexes, 2) to identify parameters influencing measures, and 3) to compare parameters before and after the administration of analgesia. Twenty-nine dogs were included. Pupillometry was feasible by a single person. There was an excellent reliability for the evaluation of pupil diameter. There was poor to good reliability for the other parameters. There was an association between weight and mean pupil diameter (estimate = 0.1 mm, CI95 = [0.0; 0.1], P = 0.02), mean diameter variation (estimate = 0.2%, CI95 = [0.0; 0.4], P = 0.01), and mean velocity (estimate = 0.08 ms, CI95 = [0.03; 0.13], P = 0.002). Male dogs had a significantly larger mean pupil diameter than females (estimate = 1.3 mm, CI95 = [0.1; 2.5], P = 0.03). Independently of weight and sex, there was an association between mean pupil diameter and pain score: the higher the pain score, the lower the mean pupil diameter. There was a correlation between mean pupil diameter and morphine dose (ρ = -0.78, P = 0.0004). There was no significant difference in pupil diameter, velocity, and latency before and after analgesic administration. In conclusion, results do not support the use of PLR measurement by pupillometry as a pain assessment technique in hospitalized conscious dogs.

Nurse-to-Nurse Familiarity and Mortality in the Critically Ill: A Multicenter Observational Study.

Rationale: Nurse-to-nurse familiarity at work should strengthen the components of teamwork and enhance its efficiency. However, its impact on patient outcomes in critical care remains poorly investigated. Objectives: To explore the role of nurse-to-nurse familiarity on inpatient deaths during ICU stay. Methods: This was a retrospective observational study in eight adult academic ICUs between January 1, 2011 and December 31, 2016. Measurements and Main Results: Nurse-to-nurse familiarity was measured across day and night 12-hour daily shifts as the mean number of previous collaborations between each nursing team member during previous shifts within the given ICU (suboptimal if <50). Primary outcome was a shift with at least one inpatient death, excluding death of patients with a decision to forego life-sustaining therapy. A multiple modified Poisson regression was computed to identify the determinants of mortality per shift, taking into account ICU, patient characteristics, patient-to-nurse and patient-to-assistant nurse ratios, nurse experience length, and workload. A total of 43,479 patients were admitted, of whom 3,311 (8%) died. The adjusted model showed a lower risk of a shift with mortality when nurse-to-nurse familiarity increased in the shift (relative risk, 0.90; 95% confidence interval per 10 shifts, 0.82-0.98; P = 0.012). Low nurse-to-nurse familiarity during the shift combined with suboptimal patient-to-nurse and patient-to-assistant nurse ratios (suboptimal if >2.5 and >4, respectively) were associated with increased risk of shift with mortality (relative risk, 1.84; 95% confidence interval, 1.15-2.96; P < 0.001). Conclusions: Shifts with low nurse-to-nurse familiarity were associated with an increased risk of patient deaths.

Burnout Syndrome During COVID-19 Second Wave on ICU Caregivers.

Objective: The main objective of this article is to evaluate the prevalence of burnout syndrome (BOS) among the Intensive Care Unit (ICU) healthcare workers. Methods: The COVID-impact study is a study conducted in 6 French intensive care units. Five units admitting COVID patient and one that doesn't admit COVID patients. The survey was conducted between October 20th and November 20th, 2020, during the second wave in France. A total of 208 professionals responded (90% response rate). The Maslach Burnout Inventory scale, the Hospital Anxiety and Depression Scale and the Impact of Event Revisited Scale were used to study the psychological impact of the COVID-19 Every intensive care unit worker. Results: The cohort includes 208 professionals, 52.4% are caregivers. Almost 20% of the respondents suffered from severe BOS. The professionals who are particularly affected by BOS are women, engaged people, nurses or reinforcement, not coming willingly to the intensive care unit and professionals with psychological disorders since COVID-19, those who are afraid of being infected, and people with anxiety, depression or post-traumatic stress disorder. Independent risk factors isolated were being engaged and being a reinforcement. Being a volunteer to come to work in ICU is protective. 19.7% of the team suffered from severe BOS during the COVID-19 pandemic in our ICU. The independent risk factors for BOS are: being engaged (OR = 3.61 (95% CI, 1.44; 9.09), don't working in ICU when it's not COVID-19 pandemic (reinforcement) (OR = 37.71 (95% CI, 3.13; 454.35), being a volunteer (OR = 0.10 (95% CI, 0.02; 0.46). Conclusion: Our study demonstrates the value of assessing burnout in health care teams. Prevention could be achieved by training personnel to form a health reserve in the event of a pandemic.

Tracheal stent aspergillosis occurring after aortic allograft of the trachea.

BACKGROUND: Aspergillosis is a fungal infection with many clinical forms. Invasive aspergillosis is the most widely known severe manifestation, but other forms can need intensive care. AIM: Our purpose is to report a case of tracheal aspergilloma and provide a review of the literature concerning endobronchial aspergillus. METHOD: We report a case of tracheal aspergilloma causing tracheal obstruction in a patient admitted in the ICU for respiratory distress. The aspergilloma occurred in a tracheal stent implanted during tracheal allograft for tracheal cancer. A combination of local and systemic antifungal was used with successful result.