Feasibility of Prone Positioning for Brain-injured Patients with Severe Acute Respiratory Distress Syndrome: A Systematic Review and Pilot Study (ProBrain).

BACKGROUND: Prone position is a key component to treat hypoxemia in patients with severe acute respiratory distress syndrome. However, most studies evaluating it exclude patients with brain injuries without any medical evidence. METHODS: This study includes a systematic review to determine whether brain-injured patients were excluded in studies evaluating prone position on acute respiratory distress syndrome; a prospective study including consecutive brain-injured patients needing prone position. The primary endpoint was the evaluation of cerebral blood flow using transcranial Doppler after prone positioning. Secondary outcomes were intracranial pressure, cerebral perfusion pressure, and tissue oxygen pressure. RESULTS: From 8,183 citations retrieved, 120 studies were included in the systematic review. Among them, 90 studies excluded brain-injured patients (75%) without any justification, 16 included brain-injured patients (4 randomized, 7 nonrandomized studies, 5 retrospective), and 14 did not retrieve brain-injured data. Eleven patients were included in the authors' pilot study. No reduction of cerebral blood flow surrogates was observed during prone positioning, with diastolic speed values (mean ± SD) ranging from 37.7 ± 16.2 cm/s to 45.2 ± 19.3 cm/s for the right side (P = 0.897) and 39.6 ± 18.2 cm/s to 46.5 ± 21.3 cm/s for the left side (P = 0.569), and pulsatility index ranging from 1.14 ± 0.31 to 1.0 ± 0.32 for the right side (P = 0.145) and 1.14 ± 0.31 to 1.02 ± 0.2 for the left side (P = 0.564) before and during prone position. CONCLUSIONS: Brain-injured patients are largely excluded from studies evaluating prone position in acute respiratory distress syndrome. However, cerebral blood flow seems not to be altered considering increasing of mean arterial pressure during the session. Systematic exclusion of brain-injured patients appears to be unfounded, and prone position, while at risk in brain-injured patients, should be evaluated on these patients to review recommendations, considering close monitoring of neurologic and hemodynamic parameters.

[Prise en charge des formes graves de Covid-19 en réanimation]. / Management of critical covid-19 in the intensive care unit.

MANAGEMENT OF CRITICAL COVID-19 IN THE INTENSIVE CARE UNIT The management of patients with severe to critical forms of Covid-19 in the intensive care unit includes oxygen therapy to treat the deep hypoxaemia induced by the disease, either delivered non-invasively (high concentration mask, high flow oxygen therapy, NIV) or invasively after oro-tracheal intubation in the most severe forms. The symptomatic management becomes then similar to that of an acute respiratory distress syndrome (ARDS) of other origin with the introduction of protective mechanical ventilation, sedation or even curarisation, and prone positioning in the most hypoxemic patients. Other organ failures, including haemodynamic and renal failures, should also be diagnosed and treated. Thrombo-prophylaxis at a higher than usual dose (intermediate or even curative dose) should also be initiated in the acute phase of the disease. Finally, specific treatment is mainly based on systemic corticosteroid therapy with dexamethasone 6 mg/d, possibly combined with tocilizumab. Other Covid-19-specific treatments have not yet been proven to be effective in critical care patients.

PRISE EN CHARGE DES FORMES GRAVES DE COVID-19 EN RÉANIMATION La prise en charge en réanimation des patients atteints d'une forme sévère à critique de Covid-19 comporte une oxygénothérapie pour lutter contre l'hypoxémie profonde induite par la maladie ; elle peut être délivrée de façon non invasive (masque à haute concentration, oxygénothérapie à haut débit, VNI) ou invasive après intubation orotrachéale dans les formes les plus sévères. La prise en charge symptomatique rejoint alors celle d'un syndrome de détresse respiratoire aiguë (SDRA) d'origine autre que celle du Covid-19, avec instauration d'une ventilation mécanique protectrice, d'une sédation voire d'une curarisation, et d'un posturage en décubitus ventral lorsque l'hypoxémie est profonde. Les autres défaillances d'organes, notamment hémodynamique et rénale, doivent également être diagnostiquées et traitées. Une thrombo-prophylaxie à dose plus élevée qu'à l'habitude (dose intermédiaire voire curative) doit être initiée à la phase aiguë de la maladie. Enfin, le traitement spécifique repose avant tout sur la corticothérapie systémique (dexaméthasone 6 mg/j), éventuellement associée au tocilizumab ; les autres traitements spécifiques de la maladie n'ont pas, à ce jour, fait la preuve de leur efficacité chez les patients en unité de soins critiques.

Massive intraoperative red blood cell transfusion during lung transplantation is strongly associated with 90-day mortality.

BACKGROUND: The effect of red blood cell (RBC) transfusion on mortality after lung transplantation (LT) was assessed in some retrospective studies, with contradictory results. The first aim of this study was to assess the 90-day survival of LT recipients according to massive intraoperative transfusion (MIOT). METHODS: This prospective, observational, single-centre study analysed the intraoperative transfusion (IOT) of all consecutive LT recipients between January 2016 and February 2019. MIOT was defined as transfusion of 5 RBC units or more. The results are presented as the median [IQR] and absolute numbers (proportions) and were analysed using χ2, Fisher, and Mann-Whitney tests (p < 0.05 as significance). Multivariate analyses were performed to identify independent risk factors for MIOT, 90-day and one-year mortality and grade 3 PGD at day 3. Ninety-day and one-year survivals were studied (Kaplan-Meier curves, log rank test). The Paris-North-Hospitals Institutional Review Board approved the study. RESULTS: Overall, 147 patients were included in the analysis, 27 (18%) of them received MIOT. In multivariate analysis, predictive factors of MIOT included preoperative ECMO support (p = 0.017), and bilateral LT (p = 0.023). The SOFA score on ICU admission after LT was higher in cases with MIOT (p < 0.001). MIOT was an independent risk factor for 90-days and one-year mortality (p = 0.002 and 0.008 respectively). The number of RBCs unit transfused during surgery was an independent risk factor for grade 3 PGD at day 3 (OR 1.14, 95% CI [1.00-1.29], p = 0.040). CONCLUSION: Increased preoperative severity of recipients predicts MIOT. MIOT is associated with increased early postoperative morbidity and mortality rates.

Intensive care readmissions in the first year after lung transplantation: Incidence, early risk factors and outcome.

BACKGROUND: Predictive factors of intensive care readmissions after lung transplantation (LT) have not been established. The main objective of this study was to assess early risk factors for ICU readmission during the first year after LT. METHODS: This retrospective, observational, single-centre study included all consecutive patients who underwent LT in our institution between January 2016 and November 2019. Patients who died during the initial hospitalisation in the ICU were excluded. Surgical and medical ICU readmissions were collected during the first year. The results are expressed as medians, interquartile ranges, absolute numbers and percentages. Statistical analyses were performed using the chi-square test, Fisher's exact test and Mann-Whitney U test as appropriate (p < 0.05 as significance). Multivariate analysis was performed to identify independent risk factors for readmission. The Paris-North-Hospitals Institutional Review Board reviewed and approved the study. RESULTS: A total of 156 patients were analysed. Eighteen of them (12%) died during the initial ICU hospitalisation. During the first year after LT, ICU readmission was observed for 49/138 (36%) patients. Among these patients, 14/49 (29%) died during the study period. Readmission was mainly related to respiratory failure (35 (71%) patients), infectious diseases (28 (57%) patients), airway complications (11 (22%) patients), and immunologic complications (4 (8%) patients). In the multivariate analysis, ICU readmission was associated with the use of high doses of catecholamines during surgery, and the increased duration of initial ICU stay. CONCLUSION: The initial severity of haemodynamic failure and a prolonged postoperative course seem to be key determinants of ICU readmissions after LT.

Blood transfusion of the donor is associated with stage 3 primary graft dysfunction after lung transplantation.

BACKGROUND: The first aim of this study was to assess the association between stage 3 PGD and pre-donation blood transfusion of the donor. The secondary objectives were to assess the epidemiology of donor transfusion and the outcome of LT recipients according to donor transfusion status and massive donor transfusion status. METHODS: This was an observational, prospective, single-center study. The results are expressed as absolute numbers, percentages, medians, and interquartile ranges. Statistical analyses were performed using Chi squared, Fischer's exact tests, and Mann-Whitney U tests (P < .05 was considered significant). A multivariate analysis was performed. RESULTS: Between January 2016 and February 2019, 147 patients were included in the analysis. PGD was observed in 79 (54%) patients, 45 (31%) of whom had stage 3 PGD. Pre-donation blood transfusion was administered in 48 (33%) donors (median of 3[1-9] packed red cells (PRCs)). On multivariate analysis, stage 3 PGD was significantly associated with donor blood transfusion (OR 2.69, IC (1.14-6.38), P = .024). Mortality at days 28 and 90 was not significantly different according to the pre-donation transfusion status of the donor. CONCLUSION: Pre-donation blood transfusion is associated with stage 3 PGD occurrence after LT. Transfusion data of the donor should be included in donor lung assessment.