Systematic review and literature appraisal on methodology of conducting and reporting critical-care echocardiography studies: a report from the European Society of Intensive Care Medicine PRICES expert panel.

BACKGROUND: The echocardiography working group of the European Society of Intensive Care Medicine recognized the need to provide structured guidance for future CCE research methodology and reporting based on a systematic appraisal of the current literature. Here is reported this systematic appraisal. METHODS: We conducted a systematic review, registered on the Prospero database. A total of 43 items of common interest to all echocardiography studies were initially listed by the experts, and other "topic-specific" items were separated into five main categories of interest (left ventricular systolic function, LVSF n = 15, right ventricular function, RVF n = 18, left ventricular diastolic function, LVDF n = 15, fluid management, FM n = 7, and advanced echocardiography techniques, AET n = 17). We evaluated the percentage of items reported per study and the fraction of studies reporting a single item. RESULTS: From January 2000 till December 2017 a total of 209 articles were included after systematic search and screening, 97 for LVSF, 48 for RVF, 51 for LVDF, 36 for FM and 24 for AET. Shock and ARDS were relatively common among LVSF articles (both around 15%) while ARDS comprised 25% of RVF articles. Transthoracic echocardiography was the main echocardiography mode, in 87% of the articles for AET topic, followed by 81% for FM, 78% for LVDF, 70% for LVSF and 63% for RVF. The percentage of items per study as well as the fraction of study reporting an item was low or very low, except for FM. As an illustration, the left ventricular size was only reported by 56% of studies in the LVSF topic, and half studies assessing RVF reported data on pulmonary artery systolic pressure. CONCLUSION: This analysis confirmed sub-optimal reporting of several items listed by an expert panel. The analysis will help the experts in the development of guidelines for CCE study design and reporting.

Prognostic significance of central venous-to-arterial carbon dioxide difference during the first 24 hours of septic shock in patients with and without impaired cardiac function.

OBJECTIVE: To investigate the prognostic significance of central venous-to-arterial carbon dioxide difference (cv-art CO 2 gap) during septic shock in patients with and without impaired cardiac function. METHODS: We performed a prospective cohort study in 10 French intensive care units. Patients suffering from septic shock were assigned to the impaired cardiac function group ('cardiac group', n =123) if they had atrial fibrillation (AF) and/or left ventricular ejection fraction (LVEF) <50% at study entry and to the non-cardiac group ( n =240) otherwise. RESULTS: Central venous and arterial blood gases were sampled every 6 h during the first 24 h to calculate cv-art CO 2 gap. Patients in the cardiac group had a higher cv-art CO 2 gap [at study entry and 6 and 12 h (all P <0.02)] than the non-cardiac group. Patients in the cardiac group with a cv-art CO 2 gap >0.9 kPa at 12 h had a higher risk of day 28 mortality (hazard ratio=3.18; P =0.0049). Among the 59 patients in the cardiac group with mean arterial pressure (MAP) ≥65 mm Hg, central venous pressure (CVP) ≥8 mm Hg and central venous oxygen saturation (ScvO 2 ) ≥70% at 12 h, those with a high cv-art CO 2 gap (>0.9 kPa; n =19) had a higher day 28 mortality (37% vs. 13%; P =0.042). In the non-cardiac group, a high cv-art CO 2 gap was not linked to a higher risk of day 28 death, whatever the threshold value of the cv-art CO 2 gap. CONCLUSION: Patients with septic shock and with AF and/or low LVEF were more prone to a persistent high cv-art CO 2 gap, even when initial resuscitation succeeded in normalizing MAP, CVP, and ScvO 2 . In these patients, a persistent high cv-art CO 2 gap at 12 h was significantly associated with higher day 28 mortality.

Predicting arterial blood gas and lactate from central venous blood analysis in critically ill patients: a multicentre, prospective, diagnostic accuracy study.

BACKGROUND: The estimation of arterial blood gas and lactate from central venous blood analysis and pulse oximetry [Formula: see text] readings has not yet been extensively validated. METHODS: In this multicentre, prospective study performed in 590 patients with acute circulatory failure, we measured blood gases and lactate in simultaneous central venous and arterial blood samples at 6 h intervals during the first 24 h after insertion of central venous and arterial catheters. The study population was randomly divided in a 2:1 ratio into model derivation and validation sets. We derived predictive models of arterial pH, carbon dioxide partial pressure, oxygen saturation, and lactate, using clinical characteristics, [Formula: see text], and central venous blood gas values as predictors, and then tested their performance in the validation set. RESULTS: In the validation set, the agreement intervals between predicted and actual values were -0.078/+0.084 units for arterial pH, -1.32/+1.36 kPa for arterial carbon dioxide partial pressure, -5.15/+4.47% for arterial oxygen saturation, and -1.07/+1.05 mmol litre(-1) for arterial lactate (i.e. around two times our predefined clinically tolerable intervals for all variables). This led to ∼5% (or less) of extreme-to-extreme misclassifications, thus giving our predictive models only marginal agreement. Thresholds of predicted variables (as determined from the derivation set) showed high predictive values (consistently >94%), to exclude abnormal arterial values in the validation set. CONCLUSIONS: Using clinical characteristics, [Formula: see text], and central venous blood analysis, we predicted arterial blood gas and lactate values with marginal accuracy in patients with circulatory failure. Further studies are required to establish whether the developed models can be used with acceptable safety.

[Barotrauma by Venturi effect during apnea testing for the determination of brain death. Should it change the terms of application of this test?]. / Barotraumatisme par effet Venturi lors du test d'apnée d'un patient en état de mort encéphalique: faut-il changer les modalités d'application de ce test?

The clinical diagnosis of brain death is based on three clinical criteria, one of them being the abolition of the spontaneous breathing shown by an apnoea testing [1,2]. During this manoeuvre, oxygen is administered by intratracheal way through oxygen supply tubing inserted into the endotracheal tube. Few cases of barotrauma with tension pneumothorax during this test have been described in the literature bringing to the loss of potential donor or grafts for transplantation. The authors report a new case of tension pneumothorax occurred during an apnoea testing despite the precautionary measures necessary to prevent such a catastrophic complication. In addition to the possible pathophysiologic explanation of the event advanced by the authors, it seems lawful to redefine the practical modalities of implementation of this test to avoid the loss of potential grafts.

Role of superantigenic strains in the prognosis of community-acquired methicillin-susceptible Staphylococcus aureus bacteraemia.

Methicillin-susceptible Staphylococcus aureus (MSSA) strains can produce superantigenic toxins that may trigger a massive release of pro-inflammatory cytokines, which are involved in the onset of septic shock. This 1-year prospective pilot study assessed the role of the production of superantigenic toxins in the outcome of immunocompetent patients hospitalised for community-acquired MSSA bacteraemia. Thirty-seven patients were enrolled, of whom 14 died in hospital. Fourteen patients had septic shock, and the mortality rate in this subgroup was 56%. Twenty-seven (73%) isolates produced at least one superantigenic toxin, but this did not influence the rate of occurrence of septic shock or death.

[Portable echocardiographs: useful or futile?]. / Echocardiographe portable: utile ou futile?

Echocardiographic systems which are the size of a laptop computer are currently available. These hand-held ultrasound units are very easy to use at patient bedside in various clinical settings. According to the miniaturized devices, spectral Doppler may not be available and power Doppler may replace true color Doppler. Validation studies of hand-held echocardiography have been conducted in critically ill patients, in patients hospitalized in ward, but also in outpatients and as a screening tool for the detection of cardiac abnormalities in the community. Hand-held echocardiography appears to have important limitations in specific clinical settings, such as shock, pulmonary hypertension, assessment of valvulopathy or valvular prosthesis, dynamic left outflow tract obstruction, left ventricular restriction or construction. The miniaturized system with spectral Doppler capability has not yet been properly validated in these indications. At its present stage of development, hand-carried ultrasound units do not allow to perform a comprehensive examination which relies on the use of a full-feature system, especially when a precise hemodynamic evaluation is required. Diagnostic ability of hand-held echocardiography is similar to that of upper-end platforms for diagnoses based on two-dimensional imaging: left ventricular systolic function, detection of wall motion abnormalities, size of cardiac chambers, identification of pericardial or pleural effusions. Hand-carried ultrasound devices may be considered as a "visual stethoscope" which provides an extension of the physical examination, but not as a potential alternative to standard transthoracic echocardiography. Its large potential clinical field of use raises the concern of taylored training programs to intensivists which could be focused on goal-directed echocardiographic examinations.

Extrapericardial cardiac tamponade caused by traumatic retrosternal hematoma.

Cardiac tamponade is an uncommon complication of blunt chest trauma, resulting typically from hemorrhage into the pericardial space. We report a case of hemodynamic compromise secondary to an extrapericardial compression caused by the acute formation of a retrosternal hematoma associated with a sternal fracture. The patient was involved in a violent deceleration accident. Initially, he only complained of an anterior thoracic pain, but subsequently became restless, pale, and dyspneic. A severe hypotension associated with sinus bradycardia (45 bpm) rapidly occurred. Both jugular veins became markedly turgescent, but no significant pulsus paradoxus was noted. Echocardiography disclosed a large hematoma, compressing anteriorly both the right ventricular cavity and outflow tract. Surgical evacuation of the retrosternal hematoma related to a bifocal fracture of the manubrium was followed by instantaneous hemodynamic improvement. Regional extrapericardial tamponade secondary to the acute formation of compressive retrosternal hematoma is an unusual cause of circulatory failure after severe blunt chest trauma. Since conventional clinical signs associated with typical tamponade physiology may be lacking in this setting, echocardiography is ideally suited for early recognition of this unusual condition.

[Hemophagocytosis during multiple organ failure: M-CSF overproduction or viral reactivation?]. / Hémophagocytose au cours des défaillances polyviscérales: implication du M-CSF ou réactivation virale?

OBJECTIVE: This study was aimed to assess the potential role of M-CSF and viral reactivation in the genesis of haemophagocytosis during the multiple organ failure (MOF) syndrome. METHODS: Twenty-five patients (mean age: 60 +/- 16 years; Apache II: 23 +/- 5) sustaining MOF with an unexplained thrombocytopenia were studied. In each patient, a bone marrow aspirate, serum M-CSF concentration, and a virological examination (Herpes viruses) were obtained on admission. In addition, 20 patients (mean age: 57 +/- 15 years; Apache II: 24 +/- 7) with at least two organ failures but no thrombocytopenia constituted the control group. Circulating M-CSF levels and the frequency of virus reactivation were compared between groups. RESULTS: Haemophagocytosis was diagnosed in 11/25 patients (44%). No viral reactivation was found. Serum M-CSF concentrations were higher in the presence of haemophagocytosis (699 +/- 242 vs 438 +/- 157 IU.mL-1; p < 0.05). Ferritin levels were also increased in the presence of a macrophage activation (3,258 +/- 2,807 vs. 520 +/- 280 mg.L-1; p < 0.0001). In contrast, both circulating M-CSF and ferritin levels were similar between thrombocytopenic patients with no hemophagocytosis and controls. CONCLUSIONS: This study confirmed the high incidence of haemophagocytosis in critically ill patients sustaining MOF. In this setting, circulating M-CSF levels were markedly elevated, whereas no Herpes viruses reactivation was found.

Differential transesophageal echocardiographic diagnosis between linear artifacts and intraluminal flap of aortic dissection or disruption.

BACKGROUND: The relatively low specificity of transesophageal echocardiography (TEE) for the diagnosis of aortic dissection (AD) or traumatic disruption of the aorta (TDA) has been attributed to linear artifacts. We sought to determine the incidence of intra-aortic linear artifacts in a cohort of patients with suspected AD or TDA, to establish the differential TEE diagnostic criteria between these artifacts and true aortic flaps, and to evaluate their impact on TEE diagnostic accuracy. METHODS AND RESULTS: During an 8-year period, patients at high risk of AD (n = 261) or TDA (n = 90) who underwent a TEE study and had confirmed final diagnoses were studied. In an initial retrospective series, linear artifacts were observed within the ascending and descending aorta in 59 of 230 patients (26%) and 17 of 230 patients (7%), respectively. TEE findings associated with linear artifacts in the ascending aorta were as follows: displacement parallel to aortic walls; similar blood flow velocities on both sides; angle with the aortic wall > 85 degrees; and thickness > 2.5 mm. Diagnostic criteria of reverberant images in the descending aorta were as follows: displacement parallel to aortic walls, overimposition of blood flow, and similar blood flow velocities on both sides of the image. In a subsequent prospective series (n = 121), systematic use of these diagnostic criteria resulted in improved TEE specificity for the identification of true intra-aortic flaps. CONCLUSIONS: Misleading intra-aortic linear artifacts are frequently observed in patients undergoing a TEE study for suspected AD or TDA. Routine use of the herein-proposed diagnostic criteria promises to further improve TEE diagnostic accuracy in the setting of severely ill patients with potential need for prompt surgery.

Comparison of multiplane transesophageal echocardiography and contrast-enhanced helical CT in the diagnosis of blunt traumatic cardiovascular injuries.

BACKGROUND: Multiplane transesophageal echocardiography (TEE) and helical computed tomography (CT) of the chest have been validated separately against aortography for the diagnosis of acute traumatic aortic injuries (ATAI). However, their respective diagnostic accuracy in identifying blunt traumatic cardiovascular lesions has not been compared. METHODS: During a 3-yr period, 110 consecutive patients with severe blunt chest trauma (age: 41 +/- 17 yr; injury severity score: 34 +/- 14) prospectively underwent TEE and chest CT as part of their initial evaluation. Results of both imaging methods were interpreted independently by experienced investigators and subsequently compared. All cases of subadventitial acute traumatic aortic injury were surgically confirmed. RESULTS: Seventeen patients had vascular injury and 11 had cardiac lesions. TEE and CT identified all subadventitial disruptions involving the aortic isthmus (n = 10) or the ascending aorta (n = 1) that necessitated surgical repair. In contrast, CT only depicted one disruption of the innominate artery. TEE detected injuries involving the intimal or medial layer, or both, of the aortic isthmus in four patients with apparently normal CT results who underwent successful conservative treatment. All cardiac injuries but two were identified only by TEE. CONCLUSIONS: In patients with severe blunt chest trauma, TEE and CT have similar diagnostic accuracy for the identification of surgical acute traumatic aortic injuy. TEE also allows the diagnosis of associated cardiac injuries and is more sensitive than CT for the identification of intimal or medial lesions of the thoracic aorta.

A new simple technique for the insertion of cuffed central venous catheters: an initial experience.

BACKGROUND: Although tunneled polyurethane catheters with polyester cuffs are useful when prolonged central venous access is necessary but their insertion still remains challenging at times. We report the first study of a new cuffed polyurethane catheter (Seldicuff) that can be easily inserted using the Seldinger technique without the need of a vein dilator and that incorporates a tunneling needle onto the catheter. A Seldicuff catheter was placed in 15 patients (mean age: 53 +/- 11 years) who required prolonged parenteral nutrition. All catheters were inserted into the right subclavian vein. The procedure lasted 6.4 +/- 0.8 minutes and no complication directly related to catheter placement was noted. Catheters remained in position for a mean duration of 103 days (range, 58 to 220 days). During this period, no infectious or mechanical complications were observed. CONCLUSION: These results demonstrate that placement of this novel cuffed catheter is as simple as inserting a conventional central venous catheter.

Intrathecal baclofen after traumatic brain injury: early treatment using a new technique to prevent spasticity.

BACKGROUND: In the early course of severe head trauma, the clinical value of intrathecal administration of baclofen to reduce autonomic disorders and spasticity has not been established. METHODS: We studied four patients (Glasgow Coma Scale score 3 or 4) with autonomic disorders and spasticity who failed to respond to conventional treatment during the early course of head injury. Baclofen (25 microg/mL) was infused continuously through an intrathecal catheter inserted at patient bedside and subcutaneously tunneled. When this treatment was successful, the spinal catheter was removed and surgically replaced by another catheter connected to a subcutaneous pump. Clinical follow-up was obtained at 6 months after the head injury. RESULTS: Mean delay for the initiation of intrathecal baclofen was 25 days (range, 21 to 31 days), and optimal dose was 385 +/- 185 microg/day. In all patients, the Ashworth score was consistently reduced (3.5 +/- 0.5 vs. 4.5 +/- 0.5 for upper limbs and 2 +/- 0.5 vs. 4.5 +/- 0.5 for lower limbs), as were both the frequency and intensity of autonomic disorders. The spinal catheters were used during a mean period of 9.5 +/- 1.7 days without complications. All three survivors were equipped with a programmable pump and had a lower Ashworth score at 6 months. Autonomic disorders had disappeared in two patients and remained modest in the remaining patient. CONCLUSION: Continuous administration of baclofen via the intrathecal route using this new technique seems to reduce autonomic disorders and spasticity during the early course of severe traumatic head injury.

Reactivation of human herpesvirus type 6 in multiple organ failure syndrome.

Human herpesvirus type 6 (HHV-6) and cytomegalovirus (CMV) are known to interact with the production of cytokines. In this study, we sought to determine the incidence of HHV-6 and CMV reactivation during multiple organ failure syndrome (MOFS) and to evaluate the potential effects of viral replication on both the morbidity and mortality associated with MOFS. Viral reactivation was assessed by use of specific polymerase chain reaction (PCR) analysis of the serum samples obtained from 48 consecutive patients with MOFS (the MOFS group) and from 48 sex- and age-matched patients with <2 organ failures (the control group). In addition, HHV-6 replication was assessed in 106 blood donors (the normal group). The incidence of HHV-6 replication was higher in the MOFS group than in the control and normal groups (26 [54%] of 48 vs. 7 [15%] of 48 and 5 [5%] of 106, respectively; P<.0001), with apparently no influence on morbidity and mortality rates. In contrast, reactivation of CMV was found in a single patient. Further studies are needed to evaluate the pathogenesis of HHV-6 replication in critically ill patients.

[Refractory shock after converting enzyme inhibitor administration. Usefulness of angiotensin II]. / Choc réfractaire après administration d'un inhibiteur de l'enzyme de conversion. Intérêt d'un traitement par angiotensine II.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors are commonly used during the early phase after myocardial infarction but severe hypotension and shock have been described. CASE REPORT: A 42-year old woman underwent a conservative management for an anterior acute myocardial infarction, initially associated with a pulmonary edema. Two hours after the initiation of a treatment with ACE inhibitor administered orally (lisinopril, Zestril), a circulatory failure in conjunction with an acute renal insufficiency occurred. Right heart catheterization disclosed markedly decreased systemic vascular resistance in the presence of a preserved cardiac index. Repeated fluid challenges and intravenous administration of norepinephrine failed to improve the hemodynamic status. The refractoriness of shock raised the hypothesis of a dysregulation of the renin-angiotensin system, secondary to the treatment by ACE inhibitor. Accordingly, the patient was given angiotensin II intravenously (Hypertension) which markedly raised systemic vascular resistance, and result in subsequent regression of shock. The patient was discharged after an otherwise uneventful course. DISCUSSION: We reported a refractory shock to fluid challenges and norepinephrine after the first dose of ACE inhibitor during acute myocardial infarction. Regression of shock was possible only with angiotensin II.

Platelet-activating factor acetylhydrolase and haemophagocytosis in the sepsis syndrome.

Sepsis syndrome (SS) is associated with depressed PAF acetylhydrolase, the enzyme responsible for the degradation of platelet activating factor. PAF acetylhydrolase is in a large part produced by macrophages, whose inadequate activation with haemophagocytosis is frequent in patients with SS. The aim of this study was to test the hypothesis that PAF acetylhydrolase levels could be affected in these critically ill patients, because of the large amounts produced by activated macrophages in vitro and in vivo in animal models. The levels of serum PAF acetylhydrolase were assessed in 90 SS patients, who were divided into three groups: patients with (n = 34) or without haemophagocytosis (n = 31), and patients without thrombocytopenia (n = 25) who were used as a control group. The number of organ dysfunctions was matched between patients with haemophagocytosis and controls. Normal reference values were obtained in 59 randomly selected blood donors. Circulating levels of PAF acetylhydrolase were significantly (p = 0.0001) decreased in patients with SS (57+/-3 nmol/ml/min, n = 90) when compared with healthy subjects (69+/-3 nmol/ml/min, n = 59). PAF acetylhydrolase levels were greater in the presence of a haemophagocytosis but without statistical significance (64.2+/-6.5 vs. 50.1+/-2.8:p = 0.25). Despite the fact that macrophagic activation stimulates the in vitro release of PAF acetylhydrolase, no difference was found between patients with or without haemophagocytosis. The mechanism and the role of the PAF acetylhydrolase reduction in SS patients remain to be determined.

Quantitative assessment of regional right ventricular function with color kinesis.

We used color kinesis, a recent echocardiographic technique that provides regional information on the magnitude and timing of endocardial wall motion, to quantitatively assess regional right ventricular (RV) systolic and diastolic properties in 76 subjects who were divided into five groups, as follows: normal (n = 20), heart failure (n = 15), pressure/volume overload (n = 14), pressure overload (n = 12), and RV hypertrophy (n = 15). Quantitative segmental analysis of color kinesis images was used to obtain regional fractional area change (RFAC), which was displayed in the form of stacked histograms to determine patterns of endocardial wall motion. Time curves of integrated RFAC were used to objectively identify asynchrony of diastolic endocardial motion. When compared with normal subjects, patients with pressure overload or heart failure exhibited significantly decreased endocardial motion along the RV free wall. In the presence of mixed pressure/volume overload, the markedly increased ventricular septal motion compensated for decreased RV free wall motion. Diastolic endocardial wall motion was delayed in 17 of 72 segments (24%) in patients with RV pressure overload, and in 31 of 90 segments (34%) in patients with RV hypertrophy. Asynchrony of diastolic endocardial wall motion was greater in the latter group than in normal subjects (16% versus 10%: p < 0.01). Segmental analysis of color kinesis images allows quantitative assessment of regional RV systolic and diastolic properties.