Thromboembolic events after major bleeding events in patients with mechanical heart valves: a 13-year analysis.

Anticoagulation in patients with mechanical heart valves (MHV) is associated with a risk of major bleeding episodes (MBE). In case of MBE, anticoagulant interruption is advocated. However, there is lack of data regarding the thrombo-embolic events (TE) risk associated with anticoagulant interruption. The main objective of the study was to evaluate the rate and risk factors of 6-months of TEs in patients with MHV experiencing MBE. This observational study was conducted over a 13-year period. Adult patients with a MHV presenting with a MBE were included. The main study endpoint was 6-month TEs, defined by clinical TEs or an echocardiographic documented thrombosis, occurring during an ICU stay or within 6-months. Thromboembolic events were recorded at ICU discharge, and 6 months after discharge. Seventy-nine MBEs were analysed, the rate of TEs at 6-months was 19% CI [11-29%]. The only difference of presentation and management between 6-month TEs and free-TE patients was the time without effective anticoagulation (TWA). The Receiver Operator Characteristic curve identified the value of 122 h of TWA as a cut-off. The multivariate analysis identified early bleeding recurrences (OR 3.62, 95% CI [1.07-12.25], p = 0.039), and TWA longer than 122 h (OR 4.24, 95% CI [1.24-14.5], p = 0.021), as independent risk factors for 6-month TEs. A higher rate of TE was associated with anticoagulation interruption longer than 5 days and early bleeding recurrences. However, the management should still be personalized and discussed for each case given the heterogeneity of causes of MBE and possibilities of haemostatic procedures.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study.

BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

Renal Replacement Therapy for Patients Requiring Extracorporeal Membrane Oxygenation: A Multicenter International Survey.

INTRODUCTION: Patients receiving extracorporeal membrane oxygenation (ECMO) often require renal replacement therapy (RRT). The challenge of inserting a dialysis catheter (DC) could be solved by direct connection of RRT lines on an ECMO circuit (DCRE) without published guidelines. This study aimed to describe the practice of RRT in patients on ECMO, including the DCRE as well as the perception and concerns related to this technique. METHODS: An international survey was worldwide sent via email to professionals involved in the management of ECMO. Respondents always or often performing RRT via the ECMO circuit were classified in the ECMO group, and those using a DC were classified in the DC group. RESULTS: From March 2019 to October 2019, 298 participants answered the questionnaire from 46 different countries. Only 28% were working in pediatric departments. Among the 165 participants commonly performing RRT in patients on ECMO, 100 (61%) performed mainly RRT via the ECMO circuit, and 65 (39%) performed RRT via DC. Pediatric practice and a longer experience were the only noticeable characteristics of the ECMO group. The most reported concern regarding DCRE was the risk of air embolism (n = 84, 28%), but the most encountered problem was unmanageable pressure alarms in RRT devices. CONCLUSION: The present study showed significant heterogeneity in RRT practices in patients on ECMO. The lower experience of the DC group, the high rates of concerns toward DCRE, and pressure alarm issues suggested that protocols and training may overcome reluctance and technical difficulties.

The Prognostic Role of Early Postoperative Troponin I in Lung Transplantation-A Retrospective 7-Year Analysis.

OBJECTIVES: Postoperative cardiac troponin I concentration is predictive of worsened outcomes in cardiac surgery. Lung transplantation (LT) surgery shares common features with cardiac surgery, but postoperative troponin has yet to be investigated. The authors aimed to evaluate the association between early postoperative troponin concentration and the 1-year mortality after transplantation. DESIGN: A retrospective, observational, single-center study. SETTING: At a tertiary care, university hospital. PARTICIPANTS: Patients who underwent lung transplantation from January 2011 to December 2017 INTERVENTIONS: For each patient, preoperative, intraoperative, and postoperative data were collected, as well as the troponin I measurement at the moment of postoperative intensive care unit admission. MEASUREMENTS AND MAIN RESULTS: Two hundred twenty LT procedures were analyzed. Troponin I was elevated in all LT patients, with a median of 3.82 ng/mL-1 (2-6.42) ng/mL-1 significantly higher in non-survivors than in survivors with 5.39 (2.88-7.44) v 3.50 ng/mL (1.74-5.76), p = 0.005. In the multivariate analysis, the authors found that only the Simplified Acute Physiology Score II score (hazard ratio [HR] 1.03; 95% confidence interval [CI] [1.001; 1.05]; p = 0.007) and the need to maintain extracorporeal life support at the end of surgery (HR 2.54; 95% CI [1.36; 4.73]; p = 0.003) were independently associated with the 1-year mortality. The multiple linear regression model found that troponin levels were associated with the need for extracorporeal life support (ECLS) (p = 0.014), the amount of transfused packed red blood cells (p = 0.008), and bilateral LT (p < 0.001). CONCLUSION: Early postoperative troponin serum levels were not independently associated with 1-year mortality. Early postoperative troponin I levels were correlated to bilateral LT, the need for ECLS, and intraoperative blood transfusion.

Morbidity and mortality related to pneumonia and TRACHEOBRONCHITIS in ICU after lung transplantation.

BACKGROUND: Bacterial respiratory infections (BRI) are major complications contributing to increased morbidity and mortality after lung transplantation (LT). This study analyzed epidemiology and outcome of 175 consecutive patients developing BRI in ICU after LT between 2006 and 2012. METHODS: Three situations were described: colonization determined in donors and recipients, pneumonia and tracheobronchitis during the first 28 postoperative days. Severity score, demographic, bacteriologic and outcome data were collected. RESULTS: 26% of donors and 31% of recipients were colonized. 92% of recipients developed BRI, including at least one episode of pneumonia in 19% of recipients. Only 21% of recipients developed BRI with an organism cultured from the donor's samples, while 40% of recipients developed BRI with their own bacteria cultured before LT. Purulent sputum appears to be an important factor to discriminate tracheobronchitis from pneumonia. When compared to patients with tracheobronchitis, those with pneumonia had longer durations of mechanical ventilation (13 [3-27] vs 3 [29], p = 0.0005) and ICU stay (24 [16-34] vs 14 [9-22], p = 0.002). Pneumonia was associated with higher 28-day (11 (32%) vs 9 (7%), p = 0.0004) and one-year mortality rates (21 (61%) vs 24 (19%), p ≤ 0.0001). CONCLUSIONS: These data confirm the high frequency of BRI right from the early postoperative period and the poor prognosis of pneumonia after LT.

Evaluation of Cardiac Index and Extravascular Lung Water After Single-Lung Transplantation Using the Transpulmonary Thermodilution Technique by the PiCCO2 Device.

OBJECTIVES: First evaluation of the transpulmonary thermodilution technique by the PiCCO2 device to assess cardiac index and pulmonary edema during the postoperative course after single-lung transplantation. DESIGN: Prospective observational study. SETTINGS: Intensive care unit, university hospital (single center). PARTICIPANTS: Single-lung transplant patients. INTERVENTIONS: The authors compared cardiac index measured by PiCCO2 and pulmonary artery catheter and assessed pulmonary edema using extravascular lung water index and pulmonary vascular permeability index measured by PiCCO2. MEASUREMENTS AND MAIN RESULTS: A Bland-Altman method was used to compare cardiac index measured by PiCCO2 and pulmonary artery catheter. Extravascular lung water index and pulmonary vascular permeability index were compared according to the PaO2/FiO2 ratio with a threshold value of 150 mmHg. Ten single-lung transplant patients were included. Cardiac index measured by PiCCO2 and pulmonary artery catheter were 3.3 L/min/m2 (2.9-3.6) and 2.5 L/min/m2 (2.2-3.0). Bias for cardiac index was 0.71 L/min/m2 (-0.03; 1.44) and limit of agreements were -0.03 and 1.44 L/min/m2. Extravascular lung water index was 12 mL/kg (11-16) and pulmonary vascular permeability index was 2.3 (2.0-3.1), consistent with pulmonary edema. Extravascular lung water index was higher in the group of PaO2/FiO2 ratio ≤150 mmHg compared with the group of PaO2/FiO2 ratio >150 mmHg (17 v 12 mL/kg, p = 0.04), whereas pulmonary vascular permeability index only tended to be higher (3.1 v 2.1, p = 0.06). CONCLUSION: PiCCO2 device systematically overestimated cardiac index compared with pulmonary artery catheter. However, it might be useful to assess pulmonary edema in acute respiratory failure after single-lung transplantation.

Characteristics and outcomes of anti-infective de-escalation during health care-associated intra-abdominal infections.

BACKGROUND: De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI. METHODS: All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital. RESULTS: Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53%), and no de-escalation was reported in 96 patients (47%) (escalation in 65 [32%] and unchanged regimen in 31 [15%]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95% CI 4.02-22.97) and empiric use of vancomycin (OR 3.39, 95% CI 1.46-7.87), carbapenems (OR 2.64, 95% CI 1.01-6.91), and aminoglycosides (OR 2.31 95% CI 1.08-4.94). The presence of NFGNB (OR 0.28, 95% CI 0.09-0.89) and the presence of MDR bacteria (OR 0.21, 95% CI 0.09-0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95% CI 1.34-5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95% CI 1.16-1.42), and age (HR 1.03, 95% CI 1.01-1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176). CONCLUSIONS: De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.

Prognosis of Prolonged Intensive Care Unit Stay After Aortic Valve Replacement for Severe Aortic Stenosis in Octogenarians.

OBJECTIVES: Octogenarians considered for cardiac surgery encounter more complications than other patients. Postoperative complications raise the question of continuation of high-cost care for patients with limited life expectancy. Duration of hospitalization in intensive care after cardiac surgery may differ between octogenarians and other patients. The objectives were evaluating the mortality rate of octogenarians experiencing prolonged hospitalization in intensive care and defining the best cut-off for prolonged intensive care unit length of stay. DESIGN: A single-center observational study. SETTING: A postoperative surgical intensive care unit in a tertiary teaching hospital in Paris, France. PARTICIPANTS: All consecutive patients older than 80 years considered for aortic valve replacement for aortic stenosis were included. MEASUREMENTS AND MAIN RESULTS: Mortality rate was determined among patients experiencing prolonged stay in intensive care with organ failure and without organ failure. An ROC curve determined the optimal cut-off defining prolonged hospitalization in intensive care according to the occurrence of postoperative complications. Multivariate analysis determined risk factors for early death or prolonged intensive care stay. The optimal cut-off defining prolonged intensive care unit length of stay was 4 days. Low ventricular ejection fraction (odds ratio [OR] = 0.95; 95% confidence interval [CI] 0.96-0.83; p = 0.0016), coronary disease (OR = 2.34; 95% CI 1.19-4.85; p = 0.014), and need for catecholamine (OR = 2.79; 95% CI 1.33-5.88; p = 0.0068) were associated with eventful postoperative course. There was not a hospitalization duration beyond which the prognosis significantly worsened. CONCLUSIONS: Prolonged length of stay in ICU without organ failure is not associated with increased mortality. No specific duration of hospitalization in intensive care was associated with increased mortality. Continuation of care should be discussed on an individual basis.

Esmolol Corrects Severe Hypoxemia in Patients with Femoro-Femoral Venoarterial Extracorporeal Life Support for Lung Transplantation.

Competitive flows syndrome result in severe regional hypoxemia when the deoxygenated flow from the native left ventricle (LV) competes with oxygenated flow from extracorporeal life support (ECLS) pump with potentially severe consequences for the cerebral and coronary circulations. Fast correction of hypoxemia could be obtained by decreasing native LV flow by infusion of a short-acting beta-blocker (esmolol). Our purpose was to retrospectively review the efficacy of esmolol in this situation and hypothesize on the potential mechanisms of action and the associated risks. This is a retrospective analysis of five clinical cases, who underwent lung transplantation and a femoro-femoral venoarterial (VA) ECLS. The patients presented severe hypoxemia (SpO2 < 85%) measured through photoplethysmography on a right hand finger. From the patients' medical records and anesthesia flowcharts, hemodynamic, right heart catheterization, echocardiography variables, and arterial blood gas results were noted before and after injection of esmolol. Mechanical ventilation and VA ECLS function variables were optimized and unchanged before and after esmolol injection. All patients had terminal respiratory failure with pulmonary hypertension and conserved LV systolic function. Immediately following esmolol injection (1.3 ± .7 mg/kg; mean ± 1 SD), SpO2 increased from 73% ± 12 to 95% ± 6; blood to arterial partial pressure in CO2 (PaCO2) decreased from 52 ± 18 to 35 ± 7 mmHg systolic pulmonary artery pressure decreased from 61 ± 8 to 50 ± 12 mmHg; the pulmonary artery oxygen saturation (SvO2); increased from 51% ± 24 to 77% ± 12; systemic arterial pressure or catecholamine requirements were unchanged. In conclusion, these results suggest that injection of esmolol allowed rapid correction of regional hypoxemia occurring during lung transplantation despite femoro-femoral VA ECLS. The mechanism is probably a decreased cardiac output of the native LV due to esmolol-induced negative inotropic and chronotropic effects without significant adverse effects on systemic tissue perfusion.

Postoperative pneumonia following cardiac surgery in non-ventilated patients versus mechanically ventilated patients: is there any difference?

INTRODUCTION: No studies have compared ventilator-associated pneumonia (VAP) and non-VAP following cardiac surgery (CS). The aim of this study was to assess the incidence, clinical and microbiologic features, treatment characteristics and prognosis of postoperative pneumonia following CS with a special focus on non-VAP. METHODS: This was a retrospective cohort study based on a prospectively collected database. We compared cases of non-VAP and VAP following CS observed between January 2005 and December 2012. Statistical analysis consisted of bivariate and multivariate analysis. RESULTS: A total of 257 (3.5%) of 7,439 consecutive CS patients developed postoperative pneumonia, including 120 (47%) cases of non-VAP. Patients with VAP had more frequent history of congestive heart failure (31% vs. 17%, P = 0.006) and longer duration of cardiopulmonary bypass (105 vs 76 min, P < 0.0001), than patients with non-VAP. No significant differences were observed between the 2 groups in terms of the types of microorganisms isolated with high proportions of Enterobacteriaceae (35%), Pseudomonas aeruginosa (20.2%) and Haemophilus spp (20.2%), except for a lower proportion of Methicillin-susceptible S. aureus in the non-VAP group (3.2% vs 7.9%, P = 0.03). In the intensive care unit, patients with non-VAP had lower sequential organ failure assessment scores than patients with VAP (8 ± 3 versus 9 ± 3, P = 0.004). On multivariate analysis, in-hospital mortality was similar in both groups (32% in the non-VAP group and 42% in the VAP group, adjusted Odds Ratio (aOR): 1.4; 95% confidence intervals (CI): 0.7-2.5; P = 0.34) and appropriate empiric antibiotic therapy was associated with a reduction of in-hospital mortality (aOR: 0.4; 95% CI: 0.2-1; P = 0.05). Piperacillin/tazobactam or imipenem monotherapy constituted appropriate empiric therapy in the two groups, with values reaching 93% and 95% with no differences between VAP and non-VAP cases. CONCLUSIONS: Intensive care patients with VAP are more severely ill than non-VAP patients following CS. Nevertheless, patients with non-VAP and VAP following CS have similar outcomes. This study suggests that the empiric antibiotic regimen in patients with pneumonia following CS should include at least a broad-spectrum antibiotic targeting non-fermenting Gram-negative bacilli, regardless of the type of pneumonia, and targeting S. aureus in VAP patients.

Dynamic changes of microbial flora and therapeutic consequences in persistent peritonitis.

INTRODUCTION: Persistent peritonitis is a frequent complication of secondary peritonitis requiring additional reoperations and antibiotic therapy. This situation raises specific concerns due to microbiological changes in peritoneal samples, especially the emergence of multidrug-resistant (MDR) strains. Although this complication has been extensively studied, the rate and dynamics of MDR strains have rarely been analysed. METHODS: We compared the clinical, microbiological and therapeutic data of consecutive ICU patients admitted for postoperative peritonitis either without subsequent reoperation (n = 122) or who underwent repeated surgery for persistent peritonitis with positive peritoneal fluid cultures (n = 98). Data collected on index surgery for the treatment of postoperative peritonitis were compared between these two groups. In the patients with persistent peritonitis, the data obtained at the first, second and third reoperations were compared with those of index surgery. Risk factors for emergence of MDR strains were assessed. RESULTS: At the time of index surgery, no parameters were able to differentiate patients with or without persistent peritonitis except for increased severity and high proportions of fungal isolates in the persistent peritonitis group. The mean time to reoperation was similar from the first to the third reoperation (range: 5 to 6 days). Septic shock was the main clinical expression of persistent peritonitis. A progressive shift of peritoneal flora was observed with the number of reoperations, comprising extinction of susceptible strains and emergence of 85 MDR strains. The proportion of patients harbouring MDR strains increased from 41% at index surgery, to 49% at the first, 54% at the second (P = 0.037) and 76% at the third reoperation (P = 0.003 versus index surgery). In multivariate analysis, the only risk factor for emergence of MDR strains was time to reoperation (OR 1.19 per day, 95%CI (1.08 to 1.33), P = 0.0006). CONCLUSIONS: Initial severity, presence of Candida in surgical samples and inadequate source control are the major risk factors for persistent peritonitis. Emergence of MDR bacteria is frequent and increases progressively with the number of reoperations. No link was demonstrated between emergence of MDR strains and antibiotic regimens, while source control and its timing appeared to be major determinants of emergence of MDR strains.

Predominant role of host proteases in myocardial damage associated with infectious endocarditis induced by Enterococcus faecalis in a rat model.

Infective endocarditis (IE) remains a life-threatening infectious disease with high morbidity and mortality. The objectives of the present study are to assess the host proteolytic activities of the vegetations and their cytotoxic potential in a rat model of experimental IE. Rats were infected with a strain of Enterococcus faecalis of particularly low virulence and weak protease expression. We tested the presence of proteases released by infiltrated leukocytes (matrix metalloproteinases and elastase) or produced in situ within the septic vegetation, such as those linked to the fibrinolytic system (plasmin and plasminogen activators). We also assessed the tissue damage induced by the infective thrombus in vitro and ex vivo. The model of IE was characterized by larger and more extensive vegetations in infected than in nonseptic rats and by an intense neutrophil infiltrate interfacing with the injured underlying tissue. Neutrophil extracellular DNA was shown to trap bacteria and to produce increased levels of cell-free DNA in plasma. Matrix metalloproteinase-9, elastase, and plasminogen activators were increased in septic versus nonseptic vegetations (as shown by zymography and immunohistology). Finally, proteolysis of the extracellular matrix and apoptosis were shown to be associated with host proteases. Bacteria exhibited no detectable proteolytic activity or direct cytotoxic effects. Bacterial membranes/dead bacteria were sufficient to induce leukocyte recruitment and activation that could promote vegetation formation and growth. Our results suggest that, despite the lack of bacterial proteases, the continuous attractant signals coming from bacterial colonies may lead to a chronic and deleterious aggression toward myocardial/valvular tissues by host proteases.

Microbiological profile of patients treated for postoperative peritonitis: temporal trends 1999-2019.

BACKGROUND: Temporal changes in the microbiological resistance profile have been reported in several life-threatening infections. However, no data have ever assessed this issue in postoperative peritonitis (POP). Our purpose was to assess the rate of multidrug-resistant organisms (MDROs) in POP over a two-decade period and to analyse their influence on the adequacy of empirical antibiotic therapy (EAT). METHODS: This retrospective monocentric analysis (1999-2019) addressed the changes over time in microbiologic data, including the emergence of MDROs and the adequacy of EAT for all intensive care unit adult patients treated for POP. The in vitro activities of 10 antibiotics were assessed to determine the most adequate EAT in the largest number of cases among 17 antibiotic regimens in patients with/without MDRO isolates. Our primary endpoint was to determine the frequency of MDRO and their temporal changes. Our second endpoint assessed the impact of MDROs on the adequacy of EAT per patient and their temporal changes based on susceptibility testing. In this analysis, the subgroup of patients with MDRO was compared with the subgroup of patients free of MDRO. RESULTS: A total of 1,318 microorganisms were cultured from 422 patients, including 188 (45%) patients harbouring MDROs. The growing proportions of MDR Enterobacterales were observed over time (p = 0.016), including ESBL-producing strains (p = 0.0013), mainly related to Klebsiella spp (p < 0.001). Adequacy of EAT was achieved in 305 (73%) patients. Decreased adequacy rates were observed when MDROs were cultured [p = 0.0001 vs. MDRO-free patients]. Over the study period, decreased adequacy rates were reported for patients receiving piperacillin/tazobactam in monotherapy or combined with vancomycin and imipenem/cilastatin combined with vancomycin (p < 0.01 in the three cases). In patients with MDROs, the combination of imipenem/cilastatin + vancomycin + amikacin or ciprofloxacin reached the highest adequacy rates (95% and 91%, respectively) and remained unchanged over time. CONCLUSIONS: We observed high proportions of MDRO in patients treated for POP associated with increasing proportions of MDR Enterobacterales over time. High adequacy rates were only achieved in antibiotic combinations involving carbapenems and vancomycin, while piperacillin/tazobactam is no longer a drug of choice for EAT in POP in infections involving MDRO.

Accuracy of a feedback device for cardiopulmonary resuscitation on a dental chair.

BACKGROUND: Conflicting studies exist about the effectiveness of cardiopulmonary resuscitation (CPR) on a dental chair. In some situations, dental surgeons are obliged to perform CPR with the patient on the chair. Feedback devices are supposed to guide the compression depth in order to improve the quality of CPR, but some devices are based on an accelerometer that can theoretically report erroneous results because of the lack of rigidity of a dental chair. OBJECTIVE: The aim of this study was to evaluate the accuracy of these devices to guide chest compressions on a dental chair. METHODS: A prospective, randomised, crossover, equivalence/non-inferiority study was conducted to compare the values of compression depths provided by the feedback device (Real CPR Help(®), delivered by Zoll© Medical Corporation, Chelmsford, MA, USA) with the real measurements provided by the manikin (Resusci Anne(®) Advanced SkillTrainer, Laerdal Medical AS©, Norway). Chest-compression-only CPR was performed by 15 Basic Life Support instructors who carried out two rounds of continuous CPR for 2 min each. Data were analysed with a correlation test, a Bland-Altman method and a Wilcoxon test. Statistical significance was defined as p<0.05. RESULTS: A significant difference was found between the mean depths of compression measured by the feedback device and the manikin on a dental chair and on the floor (p<0.0001). The feedback device overestimated the depth of chest compressions, and Bland-Altman analysis demonstrated poor agreement. CONCLUSION: This study indicates that feedback devices with accelerometer technology are not sufficiently reliable to ensure adequate chest compression on dental chairs.

Serum lactate and acute mesenteric ischaemia: An observational, controlled multicentre study.

BACKGROUND: Early diagnosis and prompt management of acute mesenteric ischaemia (AMI) are key to survival but remain extremely difficult, due to vague and non-specific symptoms. Serum lactate (SL) is commonly presented as a useful biomarker for the diagnosis or prognosis of AMI. The aim of our study was test SL (1) as a diagnostic marker and (2) as a prognostic marker for AMI. STUDY DESIGN: This was an ancillary multicentre case-control study. Patients with AMI at intensive care unit (ICU) admission were included (AMI group) and matched to ICU patients without AMI (control group). SL was measured and compared on day 0 (D0) and day 1 (D1). Diagnosis and prognosis accuracy were assessed by receiver operating characteristic (ROC) and their area under the curve (AUC). RESULTS: Each group consisted of 137 matched ICU patients. There was no significant difference of SL between the two groups at D0 or at D1 (p = 0.26 and p = 0.29 respectively). SL was a poor marker of AMI: at D0 and D1, AUC were respectively 0.57 [0.51; 0.63] and 0.60 [0.53; 0.67]. SL at D0 and D1 correctly predicted ICU mortality, independently of AMI (AUC D0: 0.69 [0.59; 0.79] vs. 0.74 [0.65; 0.82]; p = 0.51 and D1: 0.74 [0.64; 0.84] vs. 0.76 [0.66; 0.87]; p = 0.77, respectively, for control and AMI groups]. CONCLUSIONS: SL has no specific link with AMI, both for diagnosis and prognosis. SL should not be used for the diagnosis of AMI but, despite its lack of specificity, it may help to assess severity.

Relationship between liver dysfunction, lipoprotein concentration and mortality during sepsis.

BACKGROUND: High-density lipoproteins (HDLs) are synthesized by the liver and display endothelioprotective properties, including anti-inflammatory, antiapoptotic, antithrombotic and antioxidant effects. In both septic and chronic liver failure patients, a low HDL cholesterol (HDL-C) concentration is associated with overmortality. Whereas sepsis-associated liver dysfunction is poorly defined, the aim of this study was to characterize the relationship between liver dysfunction, lipoprotein concentrations and mortality in septic patients in the intensive care unit (ICU). METHODS: A prospective observational study was conducted in a university hospital ICU. All consecutive patients admitted for septic shock or sepsis were included. Total cholesterol, HDL-C, low-density lipoprotein-cholesterol (LDL-C), and triglyceride levels were assessed at admission. Sepsis-associated liver dysfunction was defined as a serum bilirubin≥ 2N or aspartate aminotransferase/alanine aminotransferase concentrations ≥ 2N. Short-term and one-year prognostic outcomes were prospectively assessed. RESULTS: A total of 219 septic patients were included, and 15% of them presented with sepsis-associated liver dysfunction at admission. Low concentrations of lipoproteins were associated with mortality at Day 28 in the overall population. Sepsis-associated liver dysfunction at admission was associated with overmortality. In this subgroup, patients had a lower HDL-C concentration than patients without hepatic dysfunction (HDL-C = 0.31 [0.25, 0.55] mmol/L vs. 0.48 [0.29, 0.73] mmol/L, p = 0.0079) but there was no relationship with the outcome. Interestingly, no correlation was observed between lipoprotein concentrations and liver dysfunction markers. CONCLUSION: Sepsis-associated liver dysfunction at ICU admission is strongly associated with overmortality and is associated with a lower HDL-C concentration. However, in this subgroup of patients, HDL-C concentration had no relationship with mortality. Further exploratory studies are needed to better understand the interaction between lipoproteins and liver dysfunction during sepsis.

Aortic rupture due to pneumococcal infection in aortoiliac stents.

We report a rare case of pneumococcal aortitis secondary to endovascular bare-metal stent infection. The patient was a 70-year-old man presenting with back pain 1 year after aortoiliac implantation of bare-metal kissing stents. Final diagnosis was microbial aortitis due to Streptococcus pneumoniae involving the stents that resulted in a contained aortic rupture requiring urgent surgical treatment. Emergency extra-anatomic revascularization, excision of the infected tissues, and appropriate antibiotic therapy led to a favorable outcome. A high index of suspicion is required in such a situation because the mortality rate is very high in the absence of appropriate treatment.

Clinical review: intrapericardial fibrinolysis in management of purulent pericarditis.

Purulent pericarditis (PP) is a potentially life-threatening disease. Reported mortality rates are between 20 and 30%. Constrictive pericarditis occurs over the course of PP in at least 3.5% of cases. The frequency of persistent PP (chronic or recurrent purulent pericardial effusion occurring despite drainage and adequate antibiotherapy) is unknown because this entity was not previously classified as a complication of PP. No consensus exists on the optimal management of PP. Nevertheless, the cornerstone of PP management is complete eradication of the focus of infection. In retrospective studies, compared to simple drainage, systematic pericardiectomy provided a prevention of constrictive pericarditis with better clinical outcome. Because of potential morbidity associated with pericardiectomy, intrapericardial fibrinolysis has been proposed as a less invasive method for prevention of persistent PP and constrictive pericarditis. Experimental data demonstrate that fibrin formation, which occurs during the first week of the disease, is an essential step in the evolution to constrictive pericarditis and persistent PP. We reviewed the literature using the MEDLINE database. We evaluated the clinical efficacy, outcome, and complications of pericardial fibrinolysis. Seventy-four cases of fibrinolysis in PP were analysed. Pericarditis of tuberculous origin were excluded. Among the 40 included cases, only two treated by late fibrinolysis encountered failure requiring pericardiectomy. No patient encountered clinical or echocardiographic features of constriction during follow-up. Only one serious complication was described. Despite the lack of definitive evidence, potential benefits of fibrinolysis as a less invasive alternative to surgery in the management of PP seem promising. Early consideration should be given to fibrinolysis in order to prevent both constrictive and persistent PP. Nevertheless, in case of failure of fibrinolysis, pericardiectomy remains the primary option for complete eradication of infection.

Relationship between lipoprotein concentrations and short-term and 1-year mortality in intensive care unit septic patients: results from the HIGHSEPS study.

BACKGROUND: High-density lipoproteins (HDLs), particles characterized by their reverse cholesterol transport function, display pleiotropic properties, including anti-inflammatory and antioxidant functions. Moreover, all lipoproteins (HDLs but also low-density lipoproteins (LDLs)) neutralize lipopolysaccharides, leading to increased bacterial clearance. These two lipoproteins decrease during sepsis, and an association between low lipoprotein levels and poor outcome was reported. The goals of this study were to characterize the lipid profile of septic patients hospitalized in our intensive care unit (ICU) and to determine the relationship with the outcome. METHODS: A prospective observational study was conducted in a university hospital ICU. All consecutive patients admitted for septic shock or sepsis were included. Total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglyceride levels were assessed at admission (day 1), at day 3, and at ICU discharge. When available, a prehospitalization lipid profile collected prior to the patient's hospitalization was compiled. Short-term and 1-year prognostic outcomes were prospectively assessed. RESULTS: A total of 205 patients were included. We found a decrease in HDL-C concentration between previous values and those at admission, followed by an additional decrease at day 3. At ICU discharge, the concentration was higher than that at day 3 but did not reach the concentration measured prior to hospitalization (prior HDL-C = 1.22 (1.04-1.57) mmol/l; day 1 HDL-C = 0.44 (0.29-0.70) mmol/l; day 3 HDL-C = 0.30 (0.25-0.48) mmol/l; and HDL-C at discharge = 0.65 (0.42-0.82) mmol/l). A similar trend was found for LDL-C (prior LDL-C = 2.7 (1.91-3.33) mmol/l; day 1 LDL-C = 1.0 (0.58-1.50) mmol/l; day 3 LDL-C = 1.04 (0.64-1.54) mmol/l; and LDL-C at discharge = 1.69 (1.26-2.21) mmol/l). Mixed models for repeated measures of lipoprotein concentrations showed a significant difference in HDL-C and LDL-C concentrations over time between survivors and nonsurvivors at day 28. An HDL-C concentration at admission of less than 0.4 mmol/l was associated with increased mortality at day 28 (log-rank test, p = 0.034) but not at 1 year (log-rank test, p = 0.24). An LDL-C concentration at admission of less than 0.72 mmol/l was associated with increased mortality at day 28 and at 1 year (log-rank test, p < 0.001 and p = 0.007, respectively). No link was found between prior lipid profile and mortality. CONCLUSIONS: We showed no relationship between the prehospitalization lipid profile and patient outcome, but low lipoprotein levels in the ICU were strongly associated with short-term mortality.