Sepsis et insuffisance respiratoire aiguë sévère (apport diagnostique de l'utilisation combinée des biomarqueurs en urgence)

Contexte : L incidence des syndromes septiques est élevée avec 50 % des cas observés en dehors de la réanimation, et le plus souvent aux urgences. Il paraît nécessaire d identifier des outils aidant le clinicien en situation d urgences pour reconnaître précocement ces états septiques et permettre ainsi une réduction significative de la mortalité. L objectif de notre travail a été d évaluer l intérêt d une analyse combinée de plusieurs biomarqueurs dans le diagnostic de sepsis devant une dyspnée aiguë grave. Méthode : Etude prospective monocentrique observationnelle de cohorte de patients admis pour dyspnée aiguë grave (SpO2 = 25 b/min. Patients with an immediate need of coronarography or with obvious spontaneous pneumothorax were excluded. Six biomarkers were measured from blood sample at admission on ED or ICU: NT B type Natriuretic Peptide (NT proBNP), cardiac troponin I (cTNI), DDimeres (DD), lactate, C-reactive protein (CRP) and procalcitonin (PCT). All clinical and biological data were recorded. An independent blinded data monitoring committee classified the patients according to all the available data including response to treatment and outcomes but blindly to biomarkers. The roles of biomarkers were assessed quantitatively and then using terciles of the distribution. The contribution of the biomarkers in the diagnosis was assessed using multiple logistic regression taking into account other clinical and biological explanatory variables. Results: 172 patients were enrolled consecutively. The final diagnosis was: severe sepsis (n=50), acute heart failure (n=42), pulmonary embolism (n=11), COPD (n=21), other causes (n=48). The 28 days mortality was 17%. Parameters independently associated with infection were: male gender (OR= 2,60; p= 0,03), systolic blood pressure 150 mm hg (OR= 0,30; p= 0,03), absence of orthopnea (OR= 0,36; p= 0,03), localized infiltrates on chest X-ray (OR= 4,25; p= 0,003) and leukocyte count > 12 G/l (OR= 2,55; p= 0.02). (AUC of the clinico-biological model = 0,820)(in this analysis, 25 patients were excluded for missing data, reducing number at 147). There was no significant association between infection diagnosis and DD, cTNI, NT proBNP,lactate. Interestingly, a CRP value of less than 5 mg/l was not discriminant in predicting infection. Adjusted on clinico-biological covariates selected, both PCT with cutpoints of 0.1 and 0.4 ng/ml ( discrimination AUC 0,856; p=0,01) and CRP with cutpoints of 30 and 100 mg/l (discrimination AUC 0,870; p 0,006) were significantly associated with the diagnosis of sepsis. Both biomarkers used simultaneously lead to a discrimination of the model (AUC 0,879). Conclusion: In this particular subpopulation, the best threshold for CRP is higher than the standard one. Biomarkers combination seems to improve performance of sepsis diagnosis.An external validation is needed to prospectively validate the clinical utility of these findings.GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Decreased Risk of Ventilator-Associated Pneumonia in Sepsis Due to Intra-Abdominal Infection.

RATIONALE: Experimental studies suggest that intra-abdominal infection (IAI) induces biological alterations that may affect the risk of lung infection. OBJECTIVES: To investigate the potential effect of IAI at ICU admission on the subsequent occurrence of ventilator-associated pneumonia (VAP). METHODS: We used data entered into the French prospective multicenter Outcomerea database in 1997-2011. Consecutive patients who had severe sepsis and/or septic shock at ICU admission and required mechanical ventilation for more than 3 days were included. Patients with acute pancreatitis were not included. MEASUREMENTS AND MAIN RESULTS: Of 2623 database patients meeting the inclusion criteria, 290 (11.1%) had IAI and 2333 (88.9%) had other infections. The IAI group had fewer patients with VAP (56 [19.3%] vs. 806 [34.5%], P<0.01) and longer time to VAP (5.0 vs.10.5 days; P<0.01). After adjustment on independent risk factors for VAP and previous antimicrobial use, IAI was associated with a decreased risk of VAP (hazard ratio, 0.62; 95% confidence interval, 0.46-0.83; P<0.0017). The pathogens responsible for VAP were not different between the groups with and without IAI (Pseudomonas aeruginosa, 345 [42.8%] and 24 [42.8%]; Enterobacteriaceae, 264 [32.8%] and 19 [34.0%]; and Staphylococcus aureus, 215 [26.7%] and 17 [30.4%], respectively). Crude ICU mortality was not different between the groups with and without IAI (81 [27.9%] and 747 [32.0%], P = 0.16). CONCLUSIONS: In our observational study of mechanically ventilated ICU patients with severe sepsis and/or septic shock, VAP occurred less often and later in the group with IAIs compared to the group with infections at other sites

Cumulative incidence plot for death in patients with and without intra-abdominal infections (IAIs).

<p>Cumulative incidence plot for death in patients with and without intra-abdominal infections (IAIs).</p

Result of the Cox model analysis of the impact of intra-abdominal infection on the subsequent risk of ventilator-associated pneumonia.

<p>IAI, intra-abdominal infection; DF, degrees of freedom; HR, hazard ratio; 95%CI, 95% confidence interval; COPD, chronic obstructive pulmonary disease; LOD, Logistic Organ Dysfunction score</p><p>Result of the Cox model analysis of the impact of intra-abdominal infection on the subsequent risk of ventilator-associated pneumonia.</p

Patient characteristics.

<p>IAI, intra-abdominal infection; IQR, interquartile range; BMI, body mass index; MOF, multiple organ failures; COPD, chronic obstructive pulmonary disease; SAPS II, Simplified Acute Physiology Score, version II; SOFA, Sequential Organ Failure Assessment; ICU, intensive care unit; VAP, ventilator-associated pneumonia</p><p>Patient characteristics.</p

Flow Chart.

<p>Flow Chart.</p

Occurrence of ventilator-associated pneumonia in patients admitted to the ICU for severe sepsis and/or septic shock related to intra-abdominal infections (IAIs) or to infections at other sites.

<p>Cumulative incidence plot.</p

Non-ventilator-associated ICU-acquired pneumonia (NV-ICU-AP) in patients with acute exacerbation of COPD: From the French OUTCOMEREA cohort

Abstract Background Non-ventilator-associated ICU-acquired pneumonia (NV-ICU-AP), a nosocomial pneumonia that is not related to invasive mechanical ventilation (IMV), has been less studied than ventilator-associated pneumonia, and never in the context of patients in an ICU for severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD), a common cause of ICU admission. This study aimed to determine the factors associated with NV-ICU-AP occurrence and assess the association between NV-ICU-AP and the outcomes of these patients. Methods Data were extracted from the French ICU database, OutcomeRea™. Using survival analyses with competing risk management, we sought the factors associated with the occurrence of NV-ICU-AP. Then we assessed the association between NV-ICU-AP and mortality, intubation rates, and length of stay in the ICU. Results Of the 844 COPD exacerbations managed in ICUs without immediate IMV, NV-ICU-AP occurred in 42 patients (5%) with an incidence density of 10.8 per 1,000 patient-days. In multivariate analysis, prescription of antibiotics at ICU admission (sHR, 0.45 [0.23; 0.86], p = 0.02) and no decrease in consciousness (sHR, 0.35 [0.16; 0.76]; p < 0.01) were associated with a lower risk of NV-ICU-AP. After adjusting for confounders, NV-ICU-AP was associated with increased 28-day mortality (HR = 3.03 [1.36; 6.73]; p < 0.01), an increased risk of intubation (csHR, 5.00 [2.54; 9.85]; p < 0.01) and with a 10-day increase in ICU length of stay (p < 0.01). Conclusion We found that NV-ICU-AP incidence reached 10.8/1000 patient-days and was associated with increased risks of intubation, 28-day mortality, and longer stay for patients admitted with AECOPD

Non-ventilator-associated ICU-acquired pneumonia (NV-ICU-AP) in patients with acute exacerbation of COPD: From the French OUTCOMEREA cohort

Abstract Background Non-ventilator-associated ICU-acquired pneumonia (NV-ICU-AP), a nosocomial pneumonia that is not related to invasive mechanical ventilation (IMV), has been less studied than ventilator-associated pneumonia, and never in the context of patients in an ICU for severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD), a common cause of ICU admission. This study aimed to determine the factors associated with NV-ICU-AP occurrence and assess the association between NV-ICU-AP and the outcomes of these patients. Methods Data were extracted from the French ICU database, OutcomeRea™. Using survival analyses with competing risk management, we sought the factors associated with the occurrence of NV-ICU-AP. Then we assessed the association between NV-ICU-AP and mortality, intubation rates, and length of stay in the ICU. Results Of the 844 COPD exacerbations managed in ICUs without immediate IMV, NV-ICU-AP occurred in 42 patients (5%) with an incidence density of 10.8 per 1,000 patient-days. In multivariate analysis, prescription of antibiotics at ICU admission (sHR, 0.45 [0.23; 0.86], p = 0.02) and no decrease in consciousness (sHR, 0.35 [0.16; 0.76]; p < 0.01) were associated with a lower risk of NV-ICU-AP. After adjusting for confounders, NV-ICU-AP was associated with increased 28-day mortality (HR = 3.03 [1.36; 6.73]; p < 0.01), an increased risk of intubation (csHR, 5.00 [2.54; 9.85]; p < 0.01) and with a 10-day increase in ICU length of stay (p < 0.01). Conclusion We found that NV-ICU-AP incidence reached 10.8/1000 patient-days and was associated with increased risks of intubation, 28-day mortality, and longer stay for patients admitted with AECOPD

Life Support Limitations in Mechanically Ventilated Stroke Patients

Objectives:. The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions. Design:. Multicenter prospective French observational study. Setting:. Fourteen ICUs of the French OutcomeRea network. PATIENTS:. From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission. INTERVENTION:. None. MEASUREMENTS AND MAIN RESULTS:. We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78–4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97–5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3–9] vs 2 d [1–6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01–2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27–4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43–3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08–4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82–0.97]). Conclusions:. In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes