Prevalence and evaluation of oropharyngeal dysphagia in patients with severe acute respiratory syndrome coronavirus 2 infection in the intensive care unit.

OBJECTIVE: The main objective was to assess the prevalence of dysphagia in the intensive care unit in patients with coronavirus disease 2019.Methods. A cohort, observational, retrospective study was conducted of patients admitted to the intensive care unit for severe acute respiratory syndrome coronavirus 2 pneumonia at the University Hospital of Rouen in France. RESULTS: Over 4 months, 58 patients were intubated and ventilated, 43 of whom were evaluated. Screening revealed post-extubation dysphagia in 62.7 per cent of patients. In univariate analysis, a significant association was found between the presence of dysphagia and: the severity of the initial pathology, the duration of intubation, the duration of curare use, the degree of muscle weakness and the severity indicated on the initial scan. At the end of intensive care unit treatment, 22 per cent of the dysphagic patients had a normal diet, 56 per cent had an adapted diet and 22 per cent still received exclusive tube feeding. CONCLUSION: Post-extubation dysphagia is frequent and needs to be investigated.

Covid-19 severe hypoxemic pneumonia: A clinical experience using high-flow nasal oxygen therapy as first-line management.

PURPOSE: To report a French experience in patients admitted to Intensive Care Unit (ICU) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requiring high fractional concentration of inspired oxygen supported by high flow nasal cannula (HFNC) as first-line therapy. METHODS: Retrospective cohort study conducted in two ICUs of a French university hospital. All consecutive patients admitted during 28-days after the first admission for SARS-CoV-2 pneumonia were screened. Demographic, clinical, respiratory support, specific therapeutics, ICU length-of-stay and survival data were collected. RESULTS: Data of 43 patients were analyzed: mainly men (72%), median age 61 (51-69) years, median body mass index of 28 (25-31) kg/m2, median simplified acute physiology score (SAPS II) of 29 (22-37) and median PaO2/fraction of inspired oxygen (FiO2) (P/F) ratio of 146 (100-189) mmHg. HFNC was initiated at ICU admission in 76% of patients. Median flow was 50 (45-50) L/min and median FiO2 was 0.6 (0.5-0.8). 79% of patients presented at least one comorbidity, mainly hypertension (58%). At day (D) 28, 32% of patients required invasive mechanical ventilation, 3 patients died in ICU. Risk factors for intubation were diabetes (10% vs. 43%, P=0.04) and extensive lesions on chest computed tomography (CT) (P=0.023). Patients with more than 25% of lesions on chest CT were more frequently intubated during ICU stay (P=0.012). At ICU admission (D1), patients with higher SAPS II and Sequential Organ Failure Assessment (SOFA) scores (respectively 39 (28-50) vs. 27 (22-31), P=0.0031 and 5 (2-8) vs. 2 (2-2.2), P=0.0019), and a lower P/F ratio (98 (63-109) vs. 178 (126-206), P=0.0005) were more frequently intubated. Among non-intubated patients, the median lowest P/F was 131 (85-180) mmHg. Four caregivers had to stop working following coronavirus 2 contamination, but did not require hospitalization. CONCLUSION: Our clinical experience supports the use of HFNC as first line-therapy in patients with SARS-COV-2 pneumonia for whom face mask oxygen does not provide adequate respiratory support.

Residents in tutored practice exchange groups have better medical reasoning as measured by script concordance test: a controlled, nonrandomized study.

STUDY OBJECTIVE: Clinical reasoning by anesthesiology residents in emergency situations where optimal management is uncertain could be improved by setting up a tutored practice exchange group. This study attempted to evaluate the impact of a practice exchange group (PEG), tutored by a senior anesthesiologist, on anesthesiology residents in emergency situations. Changes in clinical reasoning were measured by script concordance tests (SCT). DESIGN: We conducted a controlled, non-randomized study. SETTING AND PARTICIPANTS: Participants are residents in anesthesiology in Rouen, Caen and Amiens University Hospitals. INTERVENTIONS: Two resident groups were made up without randomization. The first group was the control group and consisted of residents from Amiens University Hospital and Caen University Hospital. The second study group (PEG group) consisted of residents from Rouen University Hospital, who followed weekly PEG sessions. Two groups had the same learning objectives except the PEG. MEASUREMENTS: In both the control group and the study group, each resident's clinical reasoning was assessed in the same formal manner by SCT. The primary outcome measurement of this study was to compare SCT results in the study group with PEG training (PEG group) with those without (control group). MAIN RESULTS: Performance in the SCT, expressed as degree of concordance with the expert panel (95% CI), was better in the PEG group (64% [62.1%-66%]) than in control group (60% [57.5%-62.8%])) (P= .004). CONCLUSION: Our study strongly suggests that an expert-directed, peer-conducted educational training program may improve the clinical reasoning of anesthesiology residents as measured by SCT.

Swallowing Disorders in Severe Brain Injury in the Arousal Phase.

The objective of this study was to determine the clinical characteristics of swallowing disorders in severe brain injury in the arousal phase after coma. Between December 1, 2013 and June 30, 2014, eleven patients with severe acquired brain injury who were admitted to rehabilitation center (Male 81.8 %; 40.7 ± 14.6 years) were included in the study. Evaluation of swallowing included a functional examination, clinical functional swallowing test, and naso-endoscopic swallowing test. All patients had swallowing disorders at admission. The first functional swallowing test showed oral (77.8 %) and pharyngeal (66.7 %) food bolus transport disorders; and alterations in airway protection mechanisms (80 %). Swallowing test under endoscopic control showed a disorder in swallowing coordination in 55.6 % of patients tested. Seven (63.6 %) patients resumed oral feeding within an average of 6 weeks after admission to rehabilitation center and 14 weeks after acquired brain injury. Six (85.7 %) of these seven patients continued to require modified solid and liquid textures. Swallowing disorders are a major concern in severe brain injury in the arousal phase. Early bedside assessment of swallowing is essential for detection of swallowing disorders to propose appropriate medical rehabilitation care to these patients in a state of altered consciousness.

What are the perspectives for ventilated tetraplegics? A French retrospective study of 108 patients with cervical spinal cord injury.

OBJECTIVE: Tetraplegic patients are often difficult to manage in intensive care units (ICU). The aim of our study was to calculate the incidence of patients in ICU with cervical spinal cord injury with special focus on tetraplegic patients on ventilation support and their future perspectives. MATERIALS AND METHODS: This retrospective study included patients with cervical spinal cord injury in Upper Normandy, between 2002 and 2012. Data analyzed included age, sex, past medical history, date of onset of quadriplegia, level of neurological involvement, AIS grade, and ventilatory status. RESULTS: One hundred and eight patients were included (49.0 ± 21.1 years). The most common etiology was fall (50 patients [46.3%]). Incidence was calculated at 12.7 per one million inhabitants. Tracheotomy was performed in 40.7% of patients. Long-term mechanical ventilation was required for 6.5%. At the end of the study, 9 patients (9.6%) were permanently hospitalized, 61 patients (64.9%) had returned home but none of the four ventilated patients had been discharged. CONCLUSION: The conclusion of this work is that the future of highly tetraplegic patients is compromised, especially for those who remain reliant on mechanical ventilation.

Increased prevalence of psoriasis in patients with coronary artery disease: results from a case-control study.

BACKGROUND: The incidence of myocardial events has been reported to be increased in patients with psoriasis. OBJECTIVES: To investigate whether psoriasis is an independent risk factor for coronary artery disease (CAD). METHODS: We compared the prevalence of psoriasis between case patients with a diagnosis of CAD based on coronary angiography findings and control patients with no CAD referred to the emergency surgery department for an acute noncardiovascular condition. Case and control patients were examined for the presence of psoriasis by two dermatologists. The prevalence of psoriasis was compared among patients with CAD according to CAD severity. Five-hundred cases and 500 age- and sex-matched controls were included. RESULTS: Using matched univariate analysis, the prevalence of psoriasis was about twofold higher in CAD case patients than in control patients [8·0% vs. 3·4%, odds ratio (OR) 2·64; 95% confidence interval (CI) 1·42-4·88]. Using unconditional multivariate analysis, the association of psoriasis with CAD appeared to be borderline significant (OR 1·84; 95% CI 0·99-3·40). Psoriasis in patients with CAD was significantly associated with three-vessel involvement relative to one-or two-vessel involvement (13·1% vs. 6·1%; OR 3·07; 95% CI 1·50-6·25). CONCLUSIONS: The prevalence of psoriasis is twofold higher in patients with CAD than in control patients without CAD. It is associated with a more severe coronary artery involvement.

[Interaction between hypnotic agents and the hypothalamic-pituitary-adrenocorticotropic axis during surgery]. / Modulation de l'axe hypothalamo-hypophyso-surrénalien par l'utilisation des agents hypnotiques dans le contexte chirurgical.

During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adrenal axis (HPA), which via the synthesis of glucocorticoids will modulate the intensity of the inflammatory response. Anaesthetic agents could be interacting with the HPA axis during surgery. Although etomidate currently remains in the center of the discussions, it seems, at least experimentally, that most hypnotics have the capacity to modulate the synthesis of adrenal steroids. Nevertheless, with the large literature on this subject, etomidate seems to be the most deleterious hypnotic agent on the HPA axis function. Its use should be limited when HPA axis is already altered.

Incidence of anaerobic bacteria in patients with suspected pneumonia in surgical Intensive Care Unit.

BACKGROUND: Few studies have investigated the incidence of pulmonary anaerobes in a specific population in surgical Intensive Care Unit (ICU). The objective of this work was to determine the incidence of anaerobes in surgical ICU patients with suspected pneumonia. METHODS: This was a prospective observational, single-center study. Analysis was based on data collected over 30 months from the surgical ICU of a tertiary care hospital (Rouen University Hospital), including data on risk factors for anaerobes in the lungs. Patients with suspected pneumonia (community-acquired or nosocomial) were included. Bacteriological sampling was performed by protected distal bronchial sampling (PDBS) with minilavage under bronchoscopy. Aerobic and anaerobic cultures were performed for each sample. Clinicians were only aware of aerobic results. Univariate and multivariate statistical analysis compared groups with and without anaerobes. RESULTS: A total of 134 samples were obtained from 117 patients. Surgery was performed on 74 patients (63.2%), within 24 hours of admission. Fifty-four patients (46.2%) had a chest trauma and 20 patients (17.1%) were admitted for a digestive pathology. Average age was 53.6±20.9 years and sex ratio was 5.9 (100 men/17 women). Average SAPS II was 41.6±15.1, median length of ICU stay was 23 days (25th percentile=13, 75th percentile=33), and median duration of mechanical ventilation was 21 days (25th percentile=11, 75th percentile=28). Mortality rate in ICU was 14.5%. After sampling, diagnosis of pneumonia was confirmed in 70 cases (52.2%). Anaerobe cultures were positive in 11 samples taken from 11 different patients (overall incidence 8.2%). Aerobic bacteria were also involved in 9 patients (81.8%). In univariate analysis, enteral feeding (P=0.02) and absence of catecholamines at time of sampling (P=0.003) were significantly associated with the presence of anaerobes in PDBS. Enteral nutrition was also found to be a risk factor in multivariate analysis (OR=11.8, 95% CI [1.36 to 102.4] P=0.025). Prior antianaerobic antibiotic treatment was not a protective factor. No difference was observed regarding the notion of aspiration, survival, total length of stay and duration of mechanical ventilation, or evolution of pneumonia between the two groups. CONCLUSION: Our study demonstrates the presence of anaerobic bacteria in the lung samples of patients from surgical ICU with an incidence comparable to that found in populations from medical ICU departments. Anaerobic morbidity in our study is in line with recent literature.

Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study.

BACKGROUND: Respiratory variation in pulse pressure (ΔPP) is commonly used to predict the fluid responsiveness of critically ill patients. However, some researchers have demonstrated that this measurement has several limitations. The present study was designed to evaluate the proportion of patients satisfying criteria for valid application of ΔPP at a given time-point. METHODS: A 1 day, prospective, observational, point-prevalence study was performed in 26 French intensive care units (ICUs). All patients hospitalized in the ICUs on the day of the study were included. The ΔPP validity criteria were recorded prospectively and defined as follows: (i) mechanical ventilation in the absence of spontaneous respiration; (ii) regular cardiac rhythm; (iii) tidal volume ≥8 ml kg(-1) of ideal body weight; (iv) a heart rate/respiratory rate ratio >3.6; (v) total respiratory system compliance ≥30 ml cm H2O(-1); and (vi) tricuspid annular peak systolic velocity ≥0.15 m s(-1). RESULTS: The study included 311 patients with a Simplified Acute Physiology Score II of 41 (39-43). Overall, only six (2%) patients satisfied all validity criteria. Of the 170 patients with an arterial line in place, only five (3%) satisfied the validity criteria. During the 24 h preceding the study time-point, fluid responsiveness was assessed for 79 patients. ΔPP had been used to assess fluid responsiveness in 15 of these cases (19%). CONCLUSIONS: A very low percentage of patients satisfied all criteria for valid use of ΔPP in the evaluation of fluid responsiveness. Physicians must consider limitations to the validity of ΔPP before using this variable.

[Hypothermia at admission increases the risk of pulmonary contusion's infection in intubated trauma patients]. / L'hypothermie à l'admission augmente le risque d'infection des contusions pulmonaires chez les patients polytraumatisés sous ventilation invasive.

OBJECTIVES: Pulmonary contusion (PC) is common in cases of polytrauma. The aim of this study was to perform a multivariate analysis of risk factors associated with the occurrence of infection in PC and analyze the microbiological epidemiology. PATIENTS AND METHODS: All patients with PC admitted to the intensive care unit (ICU) between January 2002 and December 2006 were included in this retrospective observational study. Patients with penetrating thoracic trauma or those who died in the 48hours following admission to hospital were excluded. Diagnosis of bacterial infection in PC was performed if hyperthermia was associated with a positive quantitative culture (103 colony forming units/mL) on the bronchial sample. Univariate analysis provided statistical difference between variables that were integrated in the multivariate analysis model. Multivariate analysis was then performed to determine the risk factors of bacterial infection in PC. RESULTS: One hundred and seventeen patients were included. The incidence of bacterial infection in PC was 33.3% (39 patients). The most frequently encountered bacteria were Haemophilus sp., Staphylococcus aureus, Enterobacteriaceae, Pseudomonas sp. and Streptococcus sp. According to multivariate analysis, the existence of hypothermia at hospital admission increased the risk of PC infection (OR=2.61; IC 95% [4.2-13.3]). CONCLUSION: In conclusion, PC was infected in 33.3% of cases. The existence of hypothermia was identified as a risk factor. A prospective study is warranted to confirm these results.

[Conditions of decision making of admission or non-admission in surgical intensive care unit]. / Conditions de prise de décision d'admission ou de non admission en réanimation chirurgicale.

OBJECTIVES: To describe the condition of the decision-making of admission and non-admission in intensive care unit. STUDY DESIGN: Non-interventional observational cohort. PATIENTS AND METHODS: Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared. RESULTS: That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given. CONCLUSION: Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.

[Reliability of pulsatile saturometry in patients with shock. Digital standard sensors are not reliable for facial measurement!]. / Fiabilité de la saturométrie pulsée chez les patients en état de choc. Les capteurs digitaux standard ne sont pas fiables sur les sites faciaux !

INTRODUCTION: Non-invasive monitoring of oxygen saturation by pulse oxymetry (SpO(2)) is sometimes perturbed on fingers during shock states. Other sites are possible (toes, forehead, nose, ear). Self-adhesive standard digital sensors are commonly used off-label in these sites. We have assessed their reliability for all of these sites. METHODS: We have studied patients presenting a stabilized shock state and receiving vasoconstrictive catecholamines. When an arterial blood gas was ordered, six SpO(2) were measured quasi-simultaneously (self-adhesive standard sensors): right and left index, toe, forehead, nose and ear. SpO(2) at "finger", "toe", "forehead", "nose" and "ear" were compared to the arterial oxygen saturation (SaO(2)) by using the Bland and Altman method. The plethysmographic curve was assessed as "correct" or "unsatisfactory". RESULTS: Hundred and ten patients were included (63 ± 15 years, SAPSII 46 ± 16, catecholamines: 0.6 ± 0.5 µg/kg/min). Plethysmographic curves are more often of "correct" quality for fingers (90%) than for the other locations (50 to 70%). Bias are low for all the locations (-0.1 to +1.5%). Limits of agreement are around ±5% for fingers and toes, but as high as ±15% for the face locations. When the analysis is restricted to plethysmographic curves of "good" quality, the limits of agreement are unchanged for fingers and toes, but improved (between ±5 to ±10%) for face locations. CONCLUSION: In patients with a shock receiving vasoconstrictive catecholamines, the reliability of SpO(2) measurements with standard sensors appears better for fingers than for toes and face locations. These standard sensors should be discouraged for facial measurement because of their low reliability, even when the plethysmographic curve seems correct. Sensors specifically designed for each facial site exist, and their reliability should be estimated in patients receiving vasoconstrictive catecholamines.

[Does pulmonary contusion expose to the risk of Streptococcus pneumoniae infections? Results of an experimental study]. / La contusion pulmonaire expose-t-elle au risque de prolifération bactérienne à pneumocoque ? Résultats d'une étude expérimentale.

OBJECTIVE: To create a reliable and reproducible model of pulmonary contusion (PC) in rats in order to evaluate the influence of PC on bacterial lung proliferation. STUDY DESIGN: Experimental. ANIMALS: Male albino CD rats. METHODS: Animals were anesthetized and a PC was performed using a spring-loaded metal bar. The existence of an isolated right PC was confirmed by macroscopic, histological and radiological analysis. This model was used to compare four randomized groups of animals. These were either injured or only anesthetized and inoculated with a pneumococcal solution concentrated in 2 or 4 log(CFU/mL). The animals' lungs were collected for microbiological culture at 24 hours. The bacterial count evolution per gram of lung was the primary endpoint. RESULTS: Twelve rats were needed to validate the model, 84 to determine the morbidity and mortality and its reproducibility and 66 to assess the intra-pulmonary bacterial proliferation. The PC obtained was unilateral and isolated in 95% of cases. Mortality rate was 43%. For a low initial inoculum concentration (2 log [CFU/mL]), there is bacterial overgrowth in the PC group versus the no-PC group (P=0.0017). This difference was not found when the inoculum was more concentrated. CONCLUSION: This experimental model is reliable and reproducible. The initially high mortality seems to decrease with the experience of operators. The CP significantly increases intra-pulmonary bacterial proliferation when the inoculation is low. A high inoculum neutralizes the effect of CP. These results suggest that enhanced prevention of micro-inhalation could be beneficial in cases of CP.

A-mode ultrasound in the diagnosis of maxillary sinusitis in ventilated patients.

PROBLEMS/OBJECTIVES: The diagnosis of maxillary sinusitis in intensive care patients remains problematic. However, it is essential since maxillary sinusitis causes numerous complications and there is an effective treatment. The aim of this study was to compare A-mode ultrasound with sinus computed tomography (CT) for the diagnosis of maxillary sinusitis in intubated patients in critical care undergoing mechanical ventilation. METHODOLOGY: Prospective clinical study in 140 maxillary sinuses in the surgical ICU of a university hospital. In each intubated and mechanically ventilated patient undergoing cerebral CT scan for any reason, a bedside A-mode ultrasonography of the maxillary sinuses was performed the same day. The A-mode ultrasound result was compared with the result of the sinus CT scan for the diagnosis of maxillary sinusitis. RESULTS: Sensitivity, specificity, positive predictive value and negative predictive value of A-mode ultrasound compared with CT were 66.7%, 94.7%, 75.0% and 92.2% respectively. All the empty sinuses were correctly identified as being empty. CONCLUSIONS: Given its very good specificity and negative predictive value, bedside A-mode ultrasound may be a useful first-line examination for intubated and mechanically ventilated patients in intensive care, especially to eliminate suspicion of maxillary sinusitis.

[Refusal of care in the intensive care: how makes decision?]. / Non-admission en réanimation: comment décider?

OBJECTIVES: Decision-making bringing to an admission or not in intensive care is complex. The aim of this study is to analyze with an ethical point of view the making decision process leading to the refusal and its consequences. It is proposed a setting in prospect through the principles of beneficence, non-maleficience, respect for autonomy, justice, and the Leonetti law. PATIENTS AND METHODS: Prospective study in surgical reanimation at the University Hospital of Rouen over 9 months (November 2007-September 2008). Systematic collection for each non-admitted patient of the general characters, the methods of decision making, immediate becoming and within 48 h Constitution of two groups: patients for whom an admission in intensive care could be an unreasonable situation of obstinacy, and patients for whom an admission in reanimation would not be about unreasonable if it occurred. RESULTS: One hundred and fifty situations were analyzed. The potentially unreasonable character of an admission does not involve necessarily a refusal of care in intensive care. The question of the lack of place and equity in the access to the care is real but relative according to the typology of the patients. The research of the respect of the autonomy of the patient is difficult but could be facilitated. The Leonetti law does not appear to be able to be a framework with the situation of refusal of care in intensive care. CONCLUSION: It is not a question of going towards a systematic admission in intensive care of any patient proposed, but to make sure that so if there is a refusal, it is carried out according to a step ethically acceptable.