PREDICT identifies precipitating events associated with the clinical course of acutely decompensated cirrhosis

Background & Aims: Acute decompensation (AD) of cirrhosis may present without acute-on-chronic liver failure (ACLF) (ADNo ACLF), or with ACLF (AD-ACLF), defined by organ failure(s). Herein, we aimed to analyze and characterize the precipitants leading to both of these AD phenotypes. Methods: The multicenter, prospective, observational PREDICT study (NCT03056612) included 1,273 non-electively hospitalized patients with AD (No ACLF = 1,071; ACLF = 202). Medical history, clinical data and laboratory data were collected at enrolment and during 90-day follow-up, with particular attention given to the following characteristics of precipitants: induction of organ dysfunction or failure, systemic inflammation, chronology, intensity, and relationship to outcome. Results: Among various clinical events, 4 distinct events were precipitants consistently related to AD: proven bacterial infections, severe alcoholic hepatitis, gastrointestinal bleeding with shock and toxic encephalopathy. Among patients with precipitants in the AD-No ACLF cohort and the AD-ACLF cohort (38% and 71%, respectively), almost all (96% and 97%, respectively) showed proven bacterial infection and severe alcoholic hepatitis, either alone or in combination with other events. Survival was similar in patients with proven bacterial infections or severe alcoholic hepatitis in both AD phenotypes. The number of precipitants was associated with significantly increased 90day mortality and was paralleled by increasing levels of surrogates for systemic inflammation. Importantly, adequate first-line antibiotic treatment of proven bacterial infections was associated with a lower ACLF development rate and lower 90-day mortality. Conclusions: This study identified precipitants that are significantly associated with a distinct clinical course and prognosis in patients with AD. Specific preventive and therapeutic strategies targeting these events may improve outcomes in patients with decompensated cirrhosis. Lay summary: Acute decompensation (AD) of cirrhosis is characterized by a rapid deterioration in patient health. Herein, we aimed to analyze the precipitating events that cause AD in patients with cirrhosis. Proven bacterial infections and severe alcoholic hepatitis, either alone or in combination, accounted for almost all (96-97%) cases of AD and acute-on-chronic liver failure. Whilst the type of precipitant was not associated with mortality, the number of precipitant(s) was. This study identified precipitants that are significantly associated with a distinct clinical course and prognosis of patients with AD. Specific preventive and therapeutic strategies targeting these events may improve patient outcomes. (c) 2020 European Association for the Study of the Liver. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Intubation difficile en chirurgie thyroïdienne (mythe ou réalité ? )

Le rôle de la chirurgie thyroïdienne comme facteur de risque d'intubation difficile (ID) est actuellement controversé. Nous avons inclus 324 patients afin d'évaluer l'incidence de l'ID avec un score d'ID et recherché des facteurs de risques prédictifs d'ID. L'incidence globale de l'ID pour cette cohorte de patient était de 11,1%. Trois groupes ont été prédéfinis : groupe sans augmentation échographique du volume de la thyroïde, groupe avec goitre palpable et groupe avec goitre non palpable. L'incidence de l'ID était respectivement de 9,9%, 12,5% et 10,7% sans différence significative. Les critères prédictifs spécifiques recherchés (palpation, goitre endothoracique, déformation des voies aériennes, signes de compression ou thyroïde maligne) n'étaient pas associés à une ID. Les critères prédictifs classiques (Limitation d'ouverture de bouche, Mallampati 3 ou 4, cou court, mobilité du cou réduite, petite distance thyromentonnière et rétrognatisme) étaient associés avec une ID.TOULOUSE3-BU Santé-Centrale (315552105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Survie des patients cirrhotiques ayant necessité une ventilation mécanique d'au moins 48 heures en réanimation

La ventilation mécanique est un facteur indépendant associé à une augmentation de la mortalité chez les patients cirrhotiques de réanimation. Le but de notre étude a été d évaluer la survie des patients cirrhotiques ventilés au moins 48 heures, à la sortie de réanimation, à 1 et 6 mois, et de rechercher des facteurs associés à la survie. Soixante dix neufs patients ont été inclus. La survie en réanimation était de 56%, 38% à 1 mois et 22% à 6 mois. II n existait pas de différence significative de durée de ventilation entre les survivants et non-survivants. Un SOFA<9 a été identifié comme facteur pronostic indépendant de survie. Il n existait pas de différence pour le score de Child-Pugh-Turcotte (CPT). Dans notre étude, la survie des patients cirrhotiques ventilés au moins 48 heures ne semble pas être influencée par la durée de la ventilation mécanique, ni par la gravité de l atteinte hépatique évaluée par le CPT. Le SOFA semble être le meilleur score associé à la survie de ces patients.Admission of cirrhotic patients in ICU is still difficult because of his high risk of mortality, even more if they need mechanical ventilation (MV). We thought that MV is not the real cause of poor outcomes but confounding criteria. To evaluate the surviving ICU hospitalization, we performed 79 patients who have been ventilated at least 48 hours in our ICU. We had 56% of patients who survived ICU. We found no difference between survivors and non survivors regarding the MV duration, and the ICU discharge. The SOFA score had the best predictive ability for survival instead of Child-Pugh score. We can explain our results, by the use of specific drugs for sedation and specific antibiotics regarding hepato-toxicity ; and by a precocious application of guidelines regarding sepsis and portal hypertension.PARIS13-BU Serge Lebovici (930082101) / SudocSudocFranceF

Definitions of Acute-On-Chronic Liver Failure: The Past, the Present, and the Future

Acute-on-chronic liver failure (ACLF) is an entity used to define patients with liver cirrhosis presenting with acute decompensation. For over 20 years, ACLF has taken multiple definitions and/or classifications. Unfortunately, to date, there has not been a universally accepted definition/classification of this entity. In this short review, we discuss the definition evolution of ACLF, the strengths and weaknesses of the existing definitions and classifications, and finally the potential role of the ‘omic’ approaches for the diagnosis of this complex syndrome

Application of LC-MS-based metabolomics method in differentiating septic survivors from non-survivors

Septic shock is the most severe form of sepsis, which is still one of the leading causes of death in the intensive care unit (ICU). Even though early prognosis and diagnosis are known to be indispensable for reaching an optimistic outcome, pathogenic complexities and the lack of specific treatment make it difficult to predict the outcome individually. In the present study, serum samples from surviving and non-surviving septic shock patients were drawn before clinical intervention at admission. Metabolic profiles of all the samples were analyzed by liquid chromatography-mass spectrometry (LC-MS)-based metabolomics. One thousand four hundred nineteen peaks in positive mode and 1878 peaks in negative mode were retained with their relative standard deviation (RSD) below 30 %, in which 187 metabolites were initially identified by retention time and database in the light of the exact molecular mass. Differences between samples from the survivors and the non-survivors were investigated using multivariate and univariate analysis. Finally, 43 significantly varied metabolites were found in the comparison between survivors and non-survivors. Concretely, metabolites in the tricarboxylic acid (TCA) cycle, amino acids, and several energy metabolism-related metabolites were up-regulated in the non-survivors, whereas those in the urea cycle and fatty acids were generally down-regulated. Metabolites such as lysine, alanine, and methionine did not present significant changes in the comparison. Six metabolites were further defined as primary discriminators differentiating the survivors from the non-survivors at the early stage of septic shock. Our findings reveal that LC-MS-based metabolomics is a useful tool for studying septic shock

Case Report Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step

We report a case of prehospital &quot;cannot intubate&quot; and &quot;cannot ventilate&quot; scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm

Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step

We report a case of prehospital “cannot intubate” and “cannot ventilate” scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm