Including Organ Dysfunctions in a Predictive Score for Nosocomial Pneumonia After Cardiothoracic Surgery.

BACKGROUND: Clinical diagnosis of ICU-acquired pneumonia after cardiothoracic surgery is challenging. Johanson criteria (chest radiograph infiltrate, purulent tracheal secretions, fever, and leukocytosis) fail in half the cases. A high Clinical Pulmonary Infection Score (CPIS) and ≥ 2-point increase in Sequential Organ Failure Assessment (SOFA) score (SOFA↑ ≥ 2) may improve diagnosis. The aim of the study was to evaluate whether CPIS or SOFA↑ ≥ 2 contributes to predict ICU-acquired pneumonia in subjects after cardiothoracic surgery. METHODS: We used a prospective observational design. Spiegelhalter-Knill-Jones scoring systems including CPIS or SOFA↑ ≥ 2, together with other clinical and laboratory variables, were developed in a derivation cohort. A positive quantitative pulmonary sample culture was required to confirm ICU-acquired pneumonia. Area under the receiver operating characteristic curve (AUROC) was computed for each of the 2 scoring systems. The best system was evaluated in a validation cohort. RESULTS: Derivation and validation cohorts included 172 and 108 subjects, with 410 and 216 suspected ICU-acquired pneumonia episodes, respectively. AUROC was 0.53 ± 0.03 for CPIS (P = .29) and 0.54 ± 0.03 for SOFA↑ ≥ 2 (P = .29). Adding purulent tracheal secretions and leukocytosis to SOFA↑ ≥ 2 (SOFA model) increased AUROC to 0.65 ± 0.03 (P < .001). Adding catecholamine use to CPIS (CPIS model) increased AUROC only slightly, to 0.57 ± 0.03. The probabilities predicted by the SOFA model were reliable, especially when high or low. CONCLUSIONS: A clinical scoring system including at least SOFA↑ ≥ 2 increase barely improved ICU-acquired pneumonia prediction in subjects after cardiothoracic surgery.

Oxygenation versus driving pressure for determining the best positive end-expiratory pressure in acute respiratory distress syndrome.

OBJECTIVE: The aim of this prospective longitudinal study was to compare driving pressure and absolute PaO2/FiO2 ratio in determining the best positive end-expiratory pressure (PEEP) level. PATIENTS AND METHODS: In 122 patients with acute respiratory distress syndrome, PEEP was increased until plateau pressure reached 30 cmH2O at constant tidal volume, then decreased at 15-min intervals, to 15, 10, and 5 cmH2O. The best PEEP by PaO2/FiO2 ratio (PEEPO2) was defined as the highest PaO2/FiO2 ratio obtained, and the best PEEP by driving pressure (PEEPDP) as the lowest driving pressure. The difference between the best PEEP levels was compared to a non-inferiority margin of 1.5 cmH2O. MAIN RESULTS: The best mean PEEPO2 value was 11.9 ± 4.7 cmH2O compared to 10.6 ± 4.1 cmH2O for the best PEEPDP: mean difference = 1.3 cmH2O (95% confidence interval [95% CI], 0.4-2.3; one-tailed P value, 0.36). Only 46 PEEP levels were the same with the two methods (37.7%; 95% CI 29.6-46.5). PEEP level was ≥ 15 cmH2O in 61 (50%) patients with PEEPO2 and 39 (32%) patients with PEEPDP (P = 0.001). CONCLUSION: Depending on the method chosen, the best PEEP level varies. The best PEEPDP level is lower than the best PEEPO2 level. Computing driving pressure is simple, faster and less invasive than measuring PaO2. However, our results do not demonstrate that one method deserves preference over the other in terms of patient outcome. CLINICAL TRIAL NUMBER: #ACTRN12618000554268 . Registered 13 April 2018.

Extubation Failure Prediction by Echography of the Diaphragm After Cardiothoracic Surgery: The EXPEDIA Study.

BACKGROUND: Successful extubation is difficult to predict. Ultrasound measurement of the diaphragm thickening fraction (DTF) might help predict weaning failure after cardiothoracic surgery. METHODS: We assessed the predictive performance of diaphragm ultrasound in a derivation cohort of 50 prospectively included cardiothoracic surgery subjects ready for a weaning trial and in a validation cohort of 39 subjects ventilated for ≥ 48 h. DTF was assessed by ultrasound during pressure support ventilation (PSV) then during a T-piece spontaneous breathing trial (SBT). DTF was the percentage change in diaphragm thickness between expiration and inspiration and DTFmax, the higher DTF value of the 2 hemidiaphragms. DTFmax during SBT (static study) and the difference in DTFmax between PSV and SBT (dynamic study) were analyzed. RESULTS: In the derivation cohort, DTFmax during SBT was 25.6 ± 17.3% in subjects with successful extubation and 65.2 ± 17.3% in those with weaning failure (difference 39.7 [95% CI 27.4-51.9], P < .01). During SBT, DTFmax ≥ 50% was associated with weaning failure (area under the receiver operating characteristic curve [AUC] 0.94 ± 0.05). In the dynamic study, a ≥ 40% DTFmax increase was associated with weaning failure (AUC 0.91 ± 0.06). In the validation cohort, DTFmax during SBT was 20.3 ± 17.1% in subjects with successful extubation and 82.0 ± 51.6% in those with weaning failure (difference 61.8 [95% CI 41.6-82.0], P < .01). During SBT, DTFmax ≥ 50% predicted weaning failure (AUC 0.99 ± 0.02). In the dynamic study, a ≥ 40% increase in DTFmax predicted weaning failure (AUC 0.81 ± 0.09). CONCLUSIONS: Measuring DTFmax during SBT and the DTFmax change when switching from PSV to SBT may help predict weaning failure after cardiothoracic surgery. The study was registered on ANZCTR. CLINICAL TRIAL REGISTRATION NUMBER: U1111-1180-1999.

Effect of Recruitment Maneuvers and PEEP on Respiratory Failure After Cardiothoracic Surgery in Obese Subjects: A Randomized Controlled Trial.

BACKGROUND: Obesity may increase the risk of respiratory failure after cardiothoracic surgery. A recruitment maneuver followed by PEEP might decrease the risk of respiratory failure in obese subjects. We hypothesized that the routine use after heart surgery of a recruitment maneuver followed by high or low PEEP level would decrease the frequency of respiratory failure in obese subjects. METHODS: In a pragmatic, randomized controlled trial, we assigned obese subjects (ie, with body mass index [BMI] ≥ 30 kg/m2) in the immediate postoperative period of cardiothoracic surgery to either volume control ventilation with 5 cm H2O of PEEP (control group) or a recruitment maneuver followed by 5 or 10 cm H2O of PEEP in the intervention arms (RM5 and RM10 groups, respectively). The primary outcome was the proportion of subjects with postextubation respiratory failure, defined as the need for re-intubation, bi-level positive airway pressure, or high-flow nasal cannula within the first 48 h. RESULTS: The study included 192 subjects: 65 in the control group (BMI 33.5 ± 3.2 kg/m2), 66 in the RM5 group (BMI 34.5 ± 3.2 kg/m2, and 61 in RM10 group (BMI 33.8 ± 4.8 kg/m2). Postextubation respiratory failure occurred in 14 subjects in the control group (21.5% [95% CI 13.3-35.3]), 21 subjects in the RM5 group (31.8% [95% CI 21.2-44.6]), and 9 subjects in the RM10 group (14.7% [95% CI 7.4-26.7]) (P = .07). The recruitment maneuver was stopped prematurely due to severe hypotension in 8 (12.1%) RM5 subjects and in 4 (6.6%) RM10 subjects (P = .28). There were no significant differences between the 3 groups for the frequencies of atelectasis, pneumonia, and death in the ICU. CONCLUSIONS: The routine use after heart surgery of a recruitment maneuver followed by 5 or 10 cm H2O of PEEP did not decrease the frequency of respiratory failure in obese subjects. A recruitment maneuver followed by 5 cm H2O of PEEP is inappropriate.

Neuromuscular Blockade Monitoring in Acute Respiratory Distress Syndrome: Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation.

BACKGROUND: Whether train-of-four (TOF) monitoring is more effective than clinical monitoring to guide neuromuscular blockade (NMB) in patients with acute respiratory distress syndrome (ARDS) is unclear. We compared clinical monitoring alone or with TOF monitoring to guide atracurium dosage adjustment with respect to drug dose and respiratory parameters. METHODS: From 2015 to 2016, we conducted a randomized controlled trial comparing clinical assessments every 2 hours with or without corrugator supercilii TOF monitoring every 4 hours in patients who developed ARDS (Pao2/Fio2 <150 mm Hg) in a cardiothoracic intensive care unit. The primary outcome was the cumulative atracurium dose (mg/kg/h). Secondary outcomes included respiratory parameters during the neuromuscular blockade. RESULTS: A total of 38 patients in the clinical + TOF (C + TOF) group and 39 patients in the clinical (C) group were included in an intention-to-treat (ITT) analysis. The cumulative atracurium dose was higher in the C + TOF group (1.06 [0.75-1.30] vs 0.65 [0.60-0.89] mg/kg/h in the C group; P < .001) compared to C group, as well as the atracurium daily dose (C + TOF - C group mean difference = 0.256 mg/kg/h [95% confidence interval {CI}, 0.099-0.416], P = .026). Driving pressures during neuromuscular blocking agent (NMBA) administration did not differ between groups (P = .653). Intensive care unit (ICU) mortality was 22% in the C group and 27% in the C + TOF group (P = .786). Days on ventilation were 17 (8-26) in the C group and 16 (10-35) in the C + TOF group. CONCLUSIONS: In patients with ARDS, adding TOF to clinical monitoring of neuromuscular blockade did not change ICU mortality or days on mechanical ventilation (MV) but did increase atracurium consumption when compared to clinical assessment alone. TOF monitoring may not be needed in all patients who receive neuromuscular blockade for ARDS.

Limitations of right ventricular annular parameters in the early postoperative period following pulmonary endarterectomy: an observational study.

OBJECTIVES: Echocardiographic right ventricular (RV) annular parameters are probably not as reliable to evaluate the surgical success in the postoperative period after pulmonary endarterectomy (PEA), whereas RV end-diastolic/left ventricular end-diastolic area ratio (RVEDA/LVEDA ratio) could be more useful. This study examined the relationship between RV annular parameters or RVEDA/LVEDA ratio and ideal cardiac index (ICI), before and after PEA. METHODS: Among 80 patients who underwent PEA, the relationships between RVEDA/LVEDA ratio (21 patients), or tricuspid annular plane systolic excursion (32 patients), or systolic tricuspid annular velocity (55 patients) and ICI were modelled. RESULTS: Forty-eight hours following PEA, mean pulmonary artery pressure decreased (26 ± 6 vs 46 ± 12 mmHg, P < 0.0001) and ICI improved (2.8 ± 0.8 vs 3.0 ± 0.9 l/min/m2, P = 0.02). In contrast to the moderate association between RV annular indices and ICI in the preoperative period, no significant relationship was found in the postoperative period (r = 0.54 and 0.17 for tricuspid annular plane systolic excursion and r = 0.46 and 0.16 for systolic tricuspid annular velocity, respectively). The RVEDA/LVEDA ratio significantly decreased postoperatively (0.97 ± 0.21 vs 1.19 ± 0.43, P = 0.002) and was correlated with ICI both in preoperative and postoperative periods (r = 0.57 and 0.57, respectively). There was a significant correlation between changes in RVEDA/LVEDA ratio and changes in total pulmonary resistance. CONCLUSIONS: Improved ICI and RVEDA/LVEDA ratio reflected the surgical success of PEA and lowering of total pulmonary resistances. In contrast to the RV/left ventricular area ratio, annular RV indices associated poorly with postoperative ICI. Recognizing this limitation is important in minimizing the overdiagnosis of RV dysfunction after PEA.

Ultrasound Assessment of Respiratory Workload With High-Flow Nasal Oxygen Versus Other Noninvasive Methods After Chest Surgery.

OBJECTIVE: To compare the respiratory workload using the diaphragm thickening fraction (DTf) determined by sonography during high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and noninvasive bilevel positive airway pressure support (BIPAP) in patients with acute respiratory failure (ARF) after cardiothoracic surgery. DESIGN: Prospective controlled clinical trial. SETTING: A French 23-bed cardiothoracic surgical intensive care unit. PARTICIPANTS: Nonintubated patients with ARF after cardiothoracic surgery or while awaiting lung transplantation. INTERVENTIONS: HFNO (50 L/min), SOT via a standard facemask, and BIPAP (pressure support, 4 cmH2O; positive end-expiratory pressure [PEEP], 4 cmH2O), with FIO2 kept constant were successively applied and compared. With BIPAP, pressure support or PEEP increments up to 8 cmH2O were compared with baseline settings. Each measurement was made after stable breathing for 5 minutes. MEASUREMENTS AND MAIN RESULTS: Fifty patients aged 60.0 ± 12.2 years were enrolled, including 14 (28%) with obesity. Mean PaO2/FIO2 was 153 ± 55 mmHg. DTf was lower with HFNO and BIPAP than with SOT (respectively 21.2% ± 15.1% v 30.9% ± 21.1% and 17.8% ± 19.1% v 30.9% ± 21.1%, p < 0.001) and was not different with HFNO versus BIPAP (p = 0.22). With BIPAP, increasing pressure support to 8 cmH2O decreased DTf (21.0% ± 14.3% v 28.8% ± 19.8%, p = 0.009), whereas increasing PEEP to 8 cmH2O did not (25.2% ± 17.2% v 28.8% ± 19.8%, p = 0.79). Tidal volume increased to 10.6 ± 3.4 mL/kg with 8 cmH2O pressure support v 8.8 ± 2.7 mL/kg with 4 cmH2O pressure support (p < 0.001). CONCLUSION: HFNO provides a comparable respiratory workload decrease compared with BIPAP at lower levels of pressure support and PEEP compared with SOT. Increasing BIPAP pressure support may provide higher levels of assistance but carries a risk of overdistension.

Efficacy of early passive tilting in minimizing ICU-acquired weakness: A randomized controlled trial.

Purpose: To investigate whether passive tilting added to a standardized rehabilitation therapy improved strength at Intensive Care Unit (ICU) discharge. Material and methods: This single-center trial included patients admitted to an adult surgical ICU and ventilated for at least 3 days. Patients were randomized to daily standardized rehabilitation therapy alone or with tilting on a table for at least 1 h. The primary outcome was the Medical Research Council (MRC) sum score at ICU discharge. Muscular recovery was a secondary outcome. Results: Of 145 included patients, 125 received mobilization, 65 in the Tilt group and 60 in the Control group. Total mobilization duration (median [25th­75th percentiles]) in the Tilt group was 1020 [580­1695] versus 1340 [536­2775] minutes in the Control group (p = 0.313). MRC sum scores at ICU discharge were not significantly different between groups (Tilt, 50 [45­56] versus 48 [45­54]; p = 0.555). However, the number of patients with weakness was higher in the Tilt group at baseline (Tilt: 60/65 versus 48/60, p = 0.045) and muscular recovery was better in the Tilt group (p = 0.004). Conclusions: Passive tilting added to a standardized rehabilitation therapy did not improve muscle strength at ICU discharge in surgical patients even if a faster recovery with tilting is suggested.

High-Flow Nasal Cannula Therapy Versus Intermittent Noninvasive Ventilation in Obese Subjects After Cardiothoracic Surgery.

BACKGROUND: Obese patients are considered at risk of respiratory failure after cardiothoracic surgery. High-flow nasal cannula has demonstrated its non-inferiority after cardiothoracic surgery compared to noninvasive ventilation (NIV), which is the recommended treatment in obese patients. We hypothesized that NIV was superior to high-flow nasal cannula for preventing or resolving acute respiratory failure after cardiothoracic surgery in this population. METHODS: We performed a post hoc analysis of a randomized, controlled trial. Obese subjects were randomly assigned to receive NIV for at least 4 h/d (inspiratory pressure, 8 cm H2O; expiratory pressure, 4 cm H2O; FIO2 , 0.5) or high-flow nasal cannula delivered continuously (flow, 50 L/min, FIO2 0.5). RESULTS: Treatment failure (defined as re-intubation, switch to the other treatment, or premature discontinuation) occurred in 21 of 136 (15.4%, 95% CI 9.8-22.6%) subjects with NIV compared to 18 of 135 (13.3%, 95% CI 8.1-20.3%) subjects with high-flow nasal cannula (P = .62). No significant differences were found for dyspnea and comfort scores. Skin breakdown was significantly more common with NIV after 24 h (9.2%, 95% CI 5.0-16.0 vs 1.6%, 95% CI 1.0-6.0; P = .01). No significant differences were found for ICU mortality (5.9% for subjects with NIV vs 2.2% for subjects with high-flow nasal cannula, P = .22) or for any of the other secondary outcomes. CONCLUSIONS: Among obese cardiothoracic surgery subjects with or without respiratory failure, the use of continuous high-flow nasal cannula compared to intermittent NIV (8/4 cm H2O) did not result in a worse rate of treatment failure. Because high-flow nasal cannula presents some advantages, it may be used instead of NIV in obese patients after cardiothoracic surgery.

Fiber optic bronchoscopy and remifentanil target-controlled infusion in critically ill patients with acute hypoxaemic respiratory failure: A descriptive study.

INTRODUCTION: Sedation optimizes patient comfort and ease of execution during fiber optic bronchoscopy (FOB). Our objective was to describe the safety and efficacy of remifentanil-TCI during FOB in non-intubated, hypoxaemic, thoracic surgery ICU patients. METHODS: Consecutive spontaneously breathing adults requiring FOB after thoracic surgery were included if they had hypoxaemia (PaO2/FiO2<300mmHg or need for non-invasive ventilation [NIV]) and prior FOB failure under topical anaesthesia. The remifentanil initial target was chosen at 1ng/mL brain effect-site concentration (Cet), then titrated to 0.5ng/mL Cet increments according to patient comfort and coughing. Outcomes were patient-reported pain and discomfort (Visual Analogue Scale scores), ventilatory support intensification within 24hours after bronchoscopy, and ease of FOB execution. RESULTS: Thirty-nine patients were included; all had a successful FOB. Their median PO2/FiO2 before starting FOB was 187±84mmHg and 24 patients received NIV. Median [interquartile range] pain scores were not different before and after FOB (1.0 [0.0-3.0] and 0.0 [0.0-2.0], respectively). Discomfort was reported as absent or minimal by 27 patients (69%; 95% confidence interval [95% CI], 54-81%) and as bothersome but tolerable by 12 patients (31%; 95% CI, 19-46%). Mean FiO2 returned to baseline within 2hours after FOB in 30 patients; the remaining 9 patients (23%; 95% CI, 13-38%) received ventilatory support intensification. Ease of execution was good or very good in 34 patients (87%; 95% CI, 73-94%), acceptable in 4 patients, and poor in 1 patient (persistent cough). CONCLUSION: Sedation with remifentanil-TCI during FOB with prior failure under topical anaesthesia alone was effective and acceptably safe in non-intubated hypoxaemic thoracic surgery patients.

Non-Ventilator ICU-Acquired Pneumonia After Cardiothoracic Surgery: Accuracy of Diagnostic Tools and Outcomes.

BACKGROUND: Non-ventilator ICU-acquired pneumonia after cardiothoracic surgery is challenging to diagnose, and little is known about its impact on patient outcomes. Here, our primary objective was to compare the sensitivity and specificity of cultures of 2 types of fiberoptic bronchoscopy (FOB) specimens: endotracheal aspirates (FOB-EA) and bronchoalveolar lavage fluid (FOB-BAL). The secondary objectives were to evaluate the sensitivity and specificity of spontaneous sputum cultures and of the modified Clinical Pulmonary Infection Score (CPIS) and to describe patient outcomes. METHODS: We conducted a prospective observational study of consecutive cardiothoracic surgery subjects with suspected non-ventilator ICU-acquired pneumonia. Using FOB-BAL cultures ≥10(4) cfu/mL as the reference standard, we evaluated the accuracy of FOB-EA ≥10(5) cfu/mL and spontaneous sputum ≥10(7) cfu/mL. On the day of FOB, we determined the modified CPIS. Mortality and antibiotic treatments were recorded. RESULTS: Of 105 subjects, 57 (54.3%) received a diagnosis of non-ventilator ICU-acquired pneumonia. FOB-EA cultures had 82% (95% CI 69-91%) sensitivity and 100% (95% CI 89-100%) specificity and were significantly less sensitive than FOB-BAL cultures (P < .004). Spontaneous sputum was obtained from one-third of subjects. Spontaneous sputum cultures had 82% (95% CI 56-95%) sensitivity and 94% (95% CI 68-100%) specificity and were non-significantly less sensitive than FOB-BAL (P = .061). A modified CPIS >6 had 42% (95% CI 29-56%) sensitivity and 87% (95% CI 74-95%) specificity for non-ventilator ICU-acquired pneumonia. Antibiotic therapy was stopped in all subjects without non-ventilator ICU-acquired pneumonia, after 1.6 ± 1.2 d, without deleterious effects. CONCLUSIONS: The modified CPIS has low diagnostic accuracy for non-ventilator ICU-acquired pneumonia. FOB-EA cultures perform less well than do FOB-BAL cultures for diagnosing non-ventilator ICU-acquired pneumonia. Spontaneous sputum is valuable when FOB cannot be performed but could be obtained in only a minority of subjects. When cultures are negative, antibiotic discontinuation is safe.

High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial.

IMPORTANCE: Noninvasive ventilation delivered as bilevel positive airway pressure (BiPAP) is often used to avoid reintubation and improve outcomes of patients with hypoxemia after cardiothoracic surgery. High-flow nasal oxygen therapy is increasingly used to improve oxygenation because of its ease of implementation, tolerance, and clinical effectiveness. OBJECTIVE: To determine whether high-flow nasal oxygen therapy was not inferior to BiPAP for preventing or resolving acute respiratory failure after cardiothoracic surgery. DESIGN AND SETTING: Multicenter, randomized, noninferiority trial (BiPOP Study) conducted between June 15, 2011, and January 15, 2014, at 6 French intensive care units. PARTICIPANTS: A total of 830 patients who had undergone cardiothoracic surgery, of which coronary artery bypass, valvular repair, and pulmonary thromboendarterectomy were the most common, were included when they developed acute respiratory failure (failure of a spontaneous breathing trial or successful breathing trial but failed extubation) or were deemed at risk for respiratory failure after extubation due to preexisting risk factors. INTERVENTIONS: Patients were randomly assigned to receive high-flow nasal oxygen therapy delivered continuously through a nasal cannula (flow, 50 L/min; fraction of inspired oxygen [FiO2], 50%) (n = 414) or BiPAP delivered with a full-face mask for at least 4 hours per day (pressure support level, 8 cm H2O; positive end-expiratory pressure, 4 cm H2O; FiO2, 50%) (n = 416). MAIN OUTCOMES AND MEASURES: The primary outcome was treatment failure, defined as reintubation, switch to the other study treatment, or premature treatment discontinuation (patient request or adverse effects, including gastric distention). Noninferiority of high-flow nasal oxygen therapy would be demonstrated if the lower boundary of the 95% CI were less than 9%. Secondary outcomes included mortality during intensive care unit stay, changes in respiratory variables, and respiratory complications. RESULTS: High-flow nasal oxygen therapy was not inferior to BiPAP: the treatment failed in 87 of 414 patients with high-flow nasal oxygen therapy (21.0%) and 91 of 416 patients with BiPAP (21.9%) (absolute difference, 0.9%; 95% CI, -4.9% to 6.6%; P = .003). No significant differences were found for intensive care unit mortality (23 patients with BiPAP [5.5%] and 28 with high-flow nasal oxygen therapy [6.8%]; P = .66) (absolute difference, 1.2% [95% CI, -2.3% to 4.8%]. Skin breakdown was significantly more common with BiPAP after 24 hours (10% vs 3%; 95% CI, 7.3%-13.4% vs 1.8%-5.6%; P < .001). CONCLUSIONS AND RELEVANCE: Among cardiothoracic surgery patients with or at risk for respiratory failure, the use of high-flow nasal oxygen therapy compared with intermittent BiPAP did not result in a worse rate of treatment failure. The findings support the use of high-flow nasal oxygen therapy in similar patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01458444.

Incidence of nosocomial pneumonia and risk of recurrence after antimicrobial therapy in critically ill lung and heart-lung transplant patients.

Little is known about the resolution of symptoms of nosocomial pneumonia (NosoP) after lung and heart-lung transplantation. The aim of this study was to describe the clinical response to antimicrobial therapy in (ICU) patients with NosoP after lung or heart-lung transplantation. Between January 2008 and August 2010, 79 lung or heart-lung transplantations patients were prospectively studied. NosoPwas confirmed by quantitative cultures of bronchoalveolar lavage or endotracheal aspirates. Clinical variables, sequential organ failure assessment (SOFA) score, and radiologic score were recorded from start of therapy until day 9. Thirty-five patients (44%) experienced 64 episodes of NosoP in ICU. Fourteen patients (40%) had NosoP recurrence. Most frequently isolated organisms were Enterobacteriaceae (30%), Pseudomonas aeruginosa (25%), and Staphylococcus aureus (20%). Sequential organ failure assessment (SOFA) score improved significantly at day 6 and C-reactive protein level at day 9. SOFA and radiologic scores differed significantly between patients with and without NosoP recurrence at day 3 and 9. The ICU mortality rate did not differ between patients with and without NosoP recurrence, and free of NosoP (14.3%, 9.5%, 11.4%, respectively) (p = 0.91). Severities of illness and lung injury were the two major risk factors for NosoP recurrence. Occurrence of NosoP has no impact on ICU mortality.

Use of prothrombin complex concentrate for excessive bleeding after cardiac surgery.

OBJECTIVES: Prothrombin complex concentrates (PCCs) are sometimes used as 'off label' for excessive bleeding after cardiopulmonary bypass (CPB). The main objective of this study was to retrospectively evaluate the clinical and biological efficacy of PCC in this setting. METHODS: We reviewed the charts of all patients who had undergone cardiac surgery under CPB in our institution for 2 years. Patients treated for active bleeding with haemostatic therapy were identified. Chest tube blood loss was quantified postoperatively in the first 24 h. Coagulation parameters were recorded at intensive care unit admission and in the patient's first 24 h. Thromboembolic complications were also ascertained. RESULTS: Seventy-seven patients out of the 677 studied (11.4%) were included: PCC was solely administered in 24 patients (group I), fresh frozen plasma in 26 (group II) and both in 27 (group III). The mean dose of PCC was 10.0 UI/kg ± 3.5 for group I vs 14.1 UI/kg ± 11.2 for group III (P = 0.09). Initial blood loss in the first hour was different between the three groups (P = 0.05): 224 ± 131 ml for group I, 369 ± 296 ml for group II and 434 ± 398 ml for group III. Only group I vs group III presented a significant difference (P = 0.02). Variations of blood loss over time were no different according to the treatment groups (P = 0.12). Reductions in blood loss expressed in percentage showed no difference between the three groups after 2 h: 54.5% (68.6-30.8) for group I; 45.0% (81.6-22.2) for group II; 57.6 (76.0-2.1) for group III; (P = 0.89). Re-exploration for bleeding involved 1 patient in group I (4%), 2 in group II (8%) and 10 in group III (37%) (P = 0.002). Except for fibrinogen, variations of prothrombin time, activated partial thromboplastin time and platelets with time were not different according to the treatment groups. Cerebral infarction occurred in one patient in group II. CONCLUSIONS: Administration of low-dose of PCC significantly decreased postoperative bleeding after CPB.

Airway responsiveness measured by forced oscillation technique in severely obese patients, before and after bariatric surgery.

BACKGROUND: The influence of obesity on airway responsiveness remains controversial. OBJECTIVE: This study was designed to investigate airway responsiveness, airway inflammation, and the influence of sleep apnea syndrome (SAS), in severely obese subjects, before and after bariatric surgery. METHODS: A total of 120 non-asthmatic obese patients were referred consecutively for pre-bariatric surgery evaluation. Lung function, airway responsiveness to methacholine, exhaled nitric oxide measurement, and sleep studies were performed. Airway hyperresponsiveness (AHR) was defined as a 50% or greater increase in respiratory resistance measured using the forced oscillation technique in response to a methacholine dose ≤ 2000 µg. Forced expiratory volume in 1 second (FEV1) was measured after the last methacholine dose. Airway responsiveness was reevaluated after weight loss in patients with a pre-surgery AHR. RESULTS: AHR was found in 16 patients. The percent FEV1 decrease or percent respiratory resistance increase in response to methacholine was related to baseline expiratory airflow (forced expiratory flow at 50%) (r = 0.26, p < .006 and r = 0.315, p = .0005, respectively) but not to body mass index (BMI) or exhaled nitric oxide. Both airway responsiveness parameters were significantly related to forced expiratory flow at 25-75%/forced vital capacity, a measure of airway size relative to lung size (r = 0.27, p < .005 and r = 0.25, p < .007, respectively). Sleep apnea was not significantly associated with AHR or airway inflammation. About 11 patients with AHR were reevaluated 18 months to 2 years after surgery, with no change in AHR associated with weight loss. CONCLUSION: Airway responsiveness is not related to BMI or to SAS. AHR in severely obese patients might be related to distal airway obstruction or low relative airway size.

Comparative effect of intraoperative propacetamol versus placebo on morphine consumption after elective reduction mammoplasty under remifentanil-based anesthesia: a randomized control trial [ISRCTN71723173].

BACKGROUND: Postoperative administration of paracetamol or its prodrug propacetamol has been shown to decrease pain with a morphine sparing effect. However, the effect of propacetamol administered intra-operatively on post-operative pain and early postoperative morphine consumption has not been clearly evaluated. In order to evaluate the effectiveness of analgesic protocols in the management of post-operative pain, a standardized anesthesia protocol without long-acting opioids is crucial. Thus, for ethical reasons, the surgical procedure under general anesthesia with remifentanil as the only intraoperative analgesic must be associated with a moderate predictable postoperative pain. METHODS: We were interested in determining the postoperative effect of propacetamol administered intraoperatively after intraoperative remifentanil. Thirty-six adult women undergoing mammoplasty with remifentanil-based anesthesia were randomly assigned to receive propacetamol 2 g or placebo one hour before the end of surgery. After remifentanil interruption and tracheal extubation in recovery room, pain was assessed and intravenous titrated morphine was given. The primary end-point was the cumulative dose of morphine administered in the recovery room. The secondary end-points were the pain score after tracheal extubation and one hour after, the delay for obtaining a Simplified Numerical Pain Scale (SNPS) less than 4, and the incidence of morphine side effects in the recovery room.For intergroup comparisons, categorical variables were compared using the chi-squared test and continuous variables were compared using the Student t test or Mann-Whitney U test, as appropriate. A p value less than 0.05 was considered as significant. RESULTS: In recovery room, morphine consumption was lower in the propacetamol group than in the placebo group (p = 0.01). Pain scores were similar in both groups after tracheal extubation and lower in the propacetamol group (p = 0.003) one hour after tracheal extubation. The time to reach a SNPS < 4 was significantly shorter in the propacetamol group (p = 0.02). The incidence of morphine related side effects did not differ between the two groups. CONCLUSIONS: Intraoperative propacetamol administration with remifentanil based-anesthesia improved significantly early postoperative pain by sparing morphine and shortening the delay to achieve pain relief.

Effect of partial liquid ventilation on bacterial clearance during Pseudomonas aeruginosa-induced lung injury in rats.

OBJECTIVE: Partial liquid ventilation (PLV) has been shown to exhibit anti-inflammatory properties during non-infectious models of acute lung injury. The aim of this experimental study was to assess the effects of PLV on bacterial clearance during Pseudomonas aeruginosa-induced pneumonia in rats. DESIGN: The rats were assigned to four groups 4 h after bacterial challenge according to the kind of mechanical ventilation [gas ventilation (GV) or PLV, 6 ml/kg perflubron plus 2 ml/kg per h] and to the level of PEEP used (3 or 8 cm of water). Physiologic measures were recorded during anesthesia (arterial blood gases, airway and blood pressures) for 4 subsequent hours until sacrifice. RESULTS: No improvement of oxygenation was demonstrated in any group. The bacterial counts were higher in PLV-PEEP 8 rats compared to GV-PEEP 8 rats: median, 1.7.10(4) cfu (25th-75th percentiles, 1.2.10(4)-1.8.10(4)) versus 1.1.10(4) (8.7.10(3)-1.3.10(4))/ml of BAL fluid and 4.0.10(6) cfu (2.0.10(6)-5.5.10(6)) versus 1.7.10(6) cfu (9.7.10(5)-3.2.10(6))/ml of lung homogenate, respectively ( P<0.05, n=8/10 surviving rats per group). PEEP 8 was associated with a significant decrease in neutrophil recruitment in BAL fluid compared to PEEP 3 in both GV and PLV groups. Additional in vitro experiments demonstrated that perflubron induced a decrease in phagocytosis of P. aeruginosa by alveolar neutrophils. CONCLUSIONS: These results demonstrate that PLV is associated with an impaired bacterial clearance during early pneumonia in rats, which could have been favored by decreased bacterial phagocytosis by neutrophils.

Effect of severe thrombocytopenia on patient outcome after liver transplantation.

OBJECTIVE: The objective was to identify factors associated with thrombocytopenia and to assess to what extent thrombocytopenia increases bleeding complications in liver transplant patients. DESIGN: Retrospective study. SETTING: Surgical intensive care unit in a university hospital. PATIENTS: One hundred and sixty-one patients admitted to the intensive care unit after liver transplantation. INTERVENTION: None. MEASUREMENTS AND RESULTS: Incidence of thrombocytopenia was defined as a platelet count of <50 x 10(9)/l for at least 3 consecutive days, associated events for thrombocytopenia or bleeding were identified by a Cox proportional hazard analysis, and blood product consumption was studied. Thrombocytopenia occurred in 104 patients (65%) with a mortality rate of 18% compared with 2% in non-thrombocytopenic patients (p=0.002). Independent associated events for thrombocytopenia were need of dialysis (hazard ratio [HR], 2.30; 95% confidence interval (95% CI), 1.10-4.80) and value of preoperative platelet count (HR, 1.06; 95% CI, 1.01-1.12 by 10(4) platelet decrease). The unique associated event identified for significant bleeding was sepsis (HR, 34.80; 95% CI, 1.47-153.40). Severe thrombocytopenia led to an excess of blood product consumption (red blood cells and platelets units) during ICU stay. CONCLUSION: Thrombocytopenia of <50 x 10(9)/l for 3 days is frequent after liver transplantation and as such is not an important contributor to bleeding. However, thrombocytopenia does reflect the severity of the postoperative course.