Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography: A Comparative Study.

BACKGROUND: To assess the agreement between transpulmonary thermodilution (TPT) and critical care echocardiography (CCE) in ventilated patients with septic shock. METHODS: Ventilated patients in sinus rhythm requiring advanced hemodynamic assessment for septic shock were included in this prospective multicenter descriptive study. Patients were assessed successively using TPT and CCE in random order. Data were interpreted independently at bedside by two investigators who proposed therapeutic changes on the basis of predefined algorithms. TPT and CCE hemodynamic assessments were reviewed offline by two independent experts who identified potential sources of discrepant results by consensus. Lactate clearance and outcome were studied. RESULTS: A total of 137 patients were studied (71 men; age, 61 ± 15 years; Simplified Acute Physiologic Score, 58 ± 18; Sequential Organ Failure Assessment, 10 ± 3). TPT and CCE interpretations at bedside were concordant in 87/132 patients (66%) without acute cor pulmonale (ACP), resulting in a moderate agreement (kappa, 0.48; 95% CI, 0.37-0.60). Experts' adjudications were concordant in 100/129 patients without ACP (77.5%), resulting in a good intertechnique agreement (kappa, 0.66; 95% CI, 0.55-0.77). In addition to ACP (n = 8), CCE depicted a potential source of TPT inaccuracy in 8/29 patients (28%). Lactate clearance at H6 was similar irrespective of the concordance of online interpretations of TPT and CCE (55/84 [65%] vs 32/45 [71%], P = .55). ICU and day 28 mortality rates were similar between patients with concordant and discordant interpretations (29/87 [36%] vs 13/45 [29%], P = .60; and 31/87 [36%] vs 16/45 [36%], P = .99, respectively). CONCLUSIONS: Agreement between TPT and CCE was moderate when interpreted at bedside and good when adjudicated offline by experts, but without impact on lactate clearance and mortality.

Fiberoptic bronchoscopy under noninvasive ventilation and propofol target-controlled infusion in hypoxemic patients.

PURPOSE: In critically ill patients with acute respiratory failure (ARF), fiberoptic bronchoscopy and bronchoalveolar lavage (FOB-BAL) are important tools in diagnostic strategies. In nonintubated patients, the patient's agitation may lead to desaturation and compromise the realization of FOB. The aim of this study was to assess the feasibility and safety of target-controlled (TCI) propofol sedation during FOB-BAL in nonintubated hypoxemic patients. METHODS: The first end point in our prospective investigation within an intensive care unit (ICU) was the avoidance of endotracheal intubation within 24 h. Secondary end points were changes in the PaO(2)/FiO(2) ratio, hemodynamic stability, patient comfort, occurrence of adverse effects, and quality of FOB. Patients self-evaluated their comfort after FOB. RESULTS: Twenty-four FOBs were performed in 23 patients with ARF. PaO(2)/FiO(2) before FOB was 181 ± 50 (range 85-286). All patients tolerated FOB with BAL. None was intubated during the 2 h after FOB. Loss of consciousness was obtained with an effect site concentration of propofol of 1.49 ± 0.46 µg/mL (range 2.6-0.6). No significant adverse events occurred. TCI propofol allowed us to obtain amnesia, patient comfort, and it did not impair airway protection. Any hemodynamic changes observed were modest and transient. CONCLUSIONS: FOB-BAL, under NIV and TCI with propofol, is feasible and safe in nonintubated patients with ARF. The TCI of propofol during FOB-BAL reduces patient discomfort with no significant adverse effects.

Short-term and long-term vital outcomes of cirrhotic patients admitted to an intensive care unit.

OBJECTIVE: To evaluate short-term and long-term vital outcomes of cirrhotic patients admitted to a general ICU, to evaluate the prognostic value of severity scores and to identify risk factors associated with death. METHODS: Observational retrospective single-center epidemiological study. All cirrhotic patients admitted to the ICU were eligible for the study. Clinical data, general ICU severity scores, and liver-specific severity scores were recorded. The mortality rate was analyzed during the stay in ICU, at day 28 and month 6 after admission. Risk factors for death were identified by univariate and multivariate analyses. RESULTS: During the study period, 86 cirrhotic patients were admitted to the ICU. The in-ICU, day-28 and month-6 mortality rates were 37, 48, and 60%, respectively. In the multivariate analysis, mechanical ventilation, the prothrombin time, and the plasma albumin level on admission were associated with the in-ICU mortality, whereas only the plasma albumin level was associated with the 6-month mortality [odds ratio 0.80; 95% confidence interval (0.70-0.92)]. The Sequential Organ Failure Assessment score was more predictive than liver-specific scores for mortality in the ICU, but not at day 28 or month 6. CONCLUSION: ICU admission should not be ruled out for patients with complicated cirrhosis. Although common in cirrhotic patients, low plasma albumin level was the only factor independently associated with short-term and long-term mortalities.