Salivary Alpha Amylase Bronchial Measure for Early Aspiration Pneumonia Diagnosis in Patients Treated With Therapeutic Hypothermia After Out-of-hospital Cardiac Arrest.

Background: Aspiration pneumonia is the most common respiratory complication following out-of-hospital cardiac arrests (OHCA). Alpha-amylase (α-amylase) in pulmonary secretions is a biomarker of interest in detecting inhalation. The main goal of this study is to evaluate the performance of bronchoalveolar levels of α-amylase in early diagnosis of aspiration pneumonia, in patients admitted to intensive care unit (ICU) after OHCA. Methods: This is a prospective single-center trial, led during 5 years (July 2015 to September 2020). We included patients admitted to ICU after OHCA. A protected specimen bronchial brushing and a mini-bronchoalveolar lavage (mini-BAL) were collected during the first 6 h after admission. Dosage of bronchial α-amylase and standard bacterial analysis were performed. Investigators confirmed pneumonia diagnosis using clinical, radiological, and microbiological criteria. Every patient underwent targeted temperature management. Results: 88 patients were included. The 34% (30 patients) developed aspiration pneumonia within 5 days following admission. The 55% (17) of pneumonias occurred during the first 48 h. The 57% of the patients received a prophylactic antibiotic treatment on their admission day. ICU mortality was 50%. Median value of bronchial α-amylase did not differ whether patients had aspiration pneumonia (15 [0-94]) or not (3 [0-61], p = 0,157). Values were significantly different concerning early-onset pneumonia (within 48 h) [19 (7-297) vs. 3 (0-82), p = 0,047]. If one or more microorganisms were detected in the initial mini-BAL, median value of α-amylase was significantly higher [25 (2-230)] than in sterile cultures (2 [0-43], p = 0,007). With an 8.5 IU/L cut-point, sensitivity and specificity of α-amylase value for predicting aspiration pneumonia during the first 2 days were respectively 74 and 62%. True positive and negative rates were respectively 44 and 86%. The area under the ROC curve was 0,654 (CI 95%; 0,524-0,785). Mechanical ventilation duration, length of ICU stay, and mortality were similar in both groups. Conclusion: In our study, dosage of bronchial α-amylase was not useful in predicting aspiration pneumonia within the first 5 days after ICU admission for OHCA. Performance in predicting early-onset pneumonia was moderate.

Pulmonary capillary blood flow and cardiac output measurement by partial carbon dioxide rebreathing in patients with acute respiratory distress syndrome receiving lung protective ventilation.

BACKGROUND: Partial carbon dioxide rebreathing noninvasively measures the pulmonary capillary blood flow and estimates the cardiac output with the use of a predicted shunt value. It has been reported that the accuracy of the method is decreased in patients with high pulmonary shunt. The aim of this study was to investigate the agreement between partial rebreathing and thermodilution for the determination of pulmonary capillary blood flow and cardiac output in the setting of acute respiratory distress syndrome. METHODS: Twenty consecutive patients with the acute respiratory distress syndrome were enrolled. Ventilator settings include low tidal volume (6 ml x kg(-1)) and positive end-expiratory pressure + 2 cm H2O higher than the lower inflection point if present or 10 cm H2O if not. Seven pairs of cardiac output and pulmonary capillary blood flows were recorded every 20 min over a 2-h period. The authors determined bias, SD, limit of agreement (95% confidence interval) and percentage error. RESULTS: Bias and agreement for cardiac output measurement were 0.8 +/- 1.2 l x min(-1) (-2.1 to 3.7 l x min(-1)), and percentage error was 36%. Bias and agreement for pulmonary capillary blood flow measurement were -0.1 +/- 0.8 l x min(-1) (-2.1 to 1.9 l x min(-1)), and percentage error was 35%. Dead space, arteriovenous oxygen content difference, mean pulmonary arterial pressure, and baseline cardiac output were independently associated with differences between methods. CONCLUSIONS: In patients with the acute respiratory distress syndrome, partial rebreathing cannot yet replace thermodilution for measuring pulmonary capillary blood flow or cardiac output. However, accuracy of the method is close to the boundary of clinical relevance.

Acute respiratory failure after drowning: a retrospective multicenter survey.

OBJECTIVES: Despite the extensive literature on drowning, clinical data are still lacking on the best medical strategy to use. Acute respiratory failure (ARF) is the main component of drowning pathophysiology. The objectives of this multicenter study were to analyze the clinical course of drowning-related ARF patients and to describe the efficacy of the ventilatory strategies used. METHODS: Medical records of drowned adult patients admitted in seven ICUs after prehospital emergency medical care during three consecutive summer periods were retrospectively analyzed. RESULTS: Among the 126 patients (58±21 years) admitted, 38 patients with cardiac arrest at the scene were not analyzed, 26 received mechanical ventilation (MV), and 48 patients received noninvasive ventilation (NIV). Compared with patients placed under MV, the NIV patients presented a better initial neurological (Glasgow Coma Scale of 7±4 vs. 12±3, P<0.05) and hemodynamic status from the prehospital stage (mean arterial pressure of 77±18 vs. 96±18, P<0.001). With comparable ARF-related hypoxemia to MV, the NIV was maintained with success in 92% (44/48). Both MV and NIV were associated with rapid improvement of oxygenation and short ICU length of stay [3 (1-14) and 2 (1-7), respectively]. CONCLUSION: Despite the absence of recommendation for NIV use in case of drowning-related ARF, this technique was often used with safety and efficacy. The decision for NIV use was mainly based on the preserved or improved neurological status.

[Beware, polyarteritis nodosa still exists in nephrology!] / Attention, la périartérite noueuse existe encore en néphrologie !

Renal involvement of systemic vasculitides is an emergency in nephrology. Although it has become very rare, the diagnosis of polyarteritis nodosa must be considered in some patients. A 70-year-old patient, previously healthy, presented with acute renal failure and malignant hypertension and abundant albuminuria. Subcutaneous nodule, orchitis and mononeuritis appeared subsequently. The search for auto-immunity or viral infection was negative. Markers of thrombotic microangiopathy, present initially, resolved after blood pressure control. After a renal computed tomography with contrast medium injection was considered normal, without any micro-aneurysm, a renal biopsy was performed. It showed vascular lesions and glomerular ischemia. It was complicated by hemorragic shock after 36hours. The diagnosis of periarteritis nodosa was finally made after arterial angiography showed millimetric renal micro-aneurysms. In case of systemic vasculitis with renal involvement, periarteritis nodosa must be part of differential diagnosis, especially in case of malignant hypertension, subcutaneous nodosa and orchitis, and despite albuminuria. This implies the search for micro-aneurysms with arterial angiography, and the contraindication of renal biopsy, associated with a high risk of severe hemorrhage. Periarteritis nodosa still exists in nephrology, even without hepatitis B infection. The association of acute renal failure with medium vessel vasculitis, with negative ANCA, must alert the nephrologist and lead to arterial angiography not to renal biopsy.

Liver Trauma in the Kitchen: Preparing Whipped Cream with a Siphon Is Not without Risk.

We report the case of a 36-year-old woman suffering from liver injury caused by the malfunction of a whipped cream siphon. When this patient handled the whipped cream siphon, the screwed metallic upper part of the siphon was suddenly dissociated from its base and came violently striking her right hypochondrium. At first, the severity of injury was underestimated. Subsequently, due to the persistence of pain experienced by the patient, an abdominal CT scan was performed. It highlighted a severe liver injury with rupture of a branch of the hepatic artery. The evolution was favorable after completion of an embolization and a secondary capsular rupture.