An integrated approach for prescribing fewer chest x-rays in the ICU

Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU

Prognosis of cirrhotic patients admitted to intensive care unit: a meta-analysis

and METAREACIR GroupInternational audienceBackgroundThe best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive care support are unknown.MethodsWe conducted meta-analyses from 13 studies (2523 cirrhotics) after selection of original articles and response to a standardized questionnaire by the corresponding authors. End-points were in-ICU, in-hospital, and 6-month mortality in ICU survivors. A total of 301 pooled analyses, including 95 analyses restricted to 6-month mortality among ICU survivors, were conducted considering 249 variables (including reason for admission, organ replacement therapy, and composite prognostic scores).ResultsIn-ICU, in-hospital, and 6-month mortality was 42.7, 54.1, and 75.1%, respectively. Forty-eight patients (3.8%) underwent liver transplantation during follow-up. In-ICU mortality was lower in patients admitted for variceal bleeding (OR 0.46; 95% CI 0.36–0.59; p 19 at baseline (OR 8.54; 95% CI 2.09–34.91; p 26 (OR 3.97; 95% CI 1.92–8.22; p < 0.0001; PPV = 0.75), and hepatorenal syndrome (OR 4.67; 95% CI 1.24–17.64; p = 0.022; PPV = 0.88).ConclusionsPrognosis of cirrhotic patients admitted to ICU is poor since only a minority undergo liver transplant. The prognostic performance of general ICU scores decreases over time, unlike the Child–Pugh and MELD scores, even recorded in the context of organ failure. Infection-related parameters had a short-term impact, whereas liver and renal failure had a sustained impact on mortality

Comparison of prognostic factors between bacteraemic and non-bacteraemic critically ill immunocompetent patients in community-acquired severe pneumococcal pneumonia: a STREPTOGENE sub-study.

BACKGROUND: The presence of bacteraemia in pneumococcal pneumonia in critically ill patients does not appear to be a strong independent prognostic factor in the existing literature. However, there may be a specific pattern of factors associated with mortality for ICU patients with bacteraemic pneumococcal community-acquired pneumonia (CAP). We aimed to compare the factors associated with mortality, according to the presence of bacteraemia or not on admission, for patients hospitalised in intensive care for severe pneumococcal CAP. METHODS: This was a post hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France between 2008 and 2012 for pneumococcal CAP. Patients were divided into two groups based on initial blood culture (positive vs. negative) for Streptococcus pneumoniae. The primary outcome was hospital mortality, which was compared between the two groups using odds ratios according to predefined variables to search for a prognostic interaction present in bacterial patients but not non-bacteraemic patients. Potential differences in the distribution of serotypes between the two groups were assessed. The prognostic consequences of the presence or not of initial bi-antibiotic therapy were assessed, specifically in bacteraemic patients. RESULTS: Among 614 included patients, 274 had a blood culture positive for S. pneumoniae at admission and 340 did not. The baseline difference between the groups was more frequent leukopaenia (26% vs. 14%, p = 0.0002) and less frequent pre-hospital antibiotic therapy (10% vs. 16.3%, p = 0.024) for the bacteraemic patients. Hospital mortality was not significantly different between the two groups (p = 0.11). We did not observe any prognostic factors specific to the bacteraemic patient population, as the statistical comparison of the odds ratios, as an indication of the association between the predefined prognostic parameters and mortality, showed them to be similar for the two groups. Bacteraemic patients more often had invasive serotypes but less often serotypes associated with high case fatality rates (p = 0.003). The antibiotic regimens were similar for the two groups. There was no difference in mortality for patients in either group given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone. CONCLUSION: Bacteraemia had no influence on the mortality of immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, regardless of the profile of the associated prognostic factors

Noninvasive ventilation in COVID-19 patients aged ≥ 70 years—a prospective multicentre cohort study

Funding Information: COVIP study did not have any funding. Publication of this article was funded by the Priority Research Area qLife under the program “Excellence Initiative – Research University” at the Jagiellonian University in Krakow (06/IDUB/2019/94). Publisher Copyright: © 2022, The Author(s).Background: Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV. Methods: This is a substudy of COVIP study—an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality. Results: Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36–5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06–2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI − 2.27 to − 0.46 days) compared to primary IMV group (n = 1876). Conclusions: Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV. Clinical Trial RegistrationNCT04321265, registered 19 March 2020, https://clinicaltrials.gov.publishersversionpublishe

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Prévalence de l'insuffisance surrénale au cours de la cirrhose (intérêt du dosage du cortisol salivaire)

L insuffisance surrénale semble fréquente chez les malades atteints de cirrhose selon les dosages du cortisol plasmatique, dont seuls 10% représentent la partie active, les 90% restants étant liés à des protéines de transport comme l albumine, dont la synthèse est diminuée en cas de cirrhose. La prévalence de l insuffisance surrénale en cas de cirrhose pourrait donc être surestimée. A l inverse, le dosage du cortisol salivaire reflète la concentration plasmatique du cortisol libre. Les objectifs de ce travail sont, au moyen d une étude prospective, (1) préciser la prévalence de l insuffisance surrénale chez les malades atteints de cirrhose, au moyen des dosages du cortisol salivaire ; (2) comparer cette prévalence à celle obtenue au moyen des dosages plasmatiques de cortisol ; (3) rechercher les facteurs de risque d insuffisance surrénale en cas de cirrhose. Pour cela, on prend des dosages du cortisol salivaire et plasmatique avant (T0) puis 1 heure après (T60) un test à la corticotropine chez des malades hospitalisés pour complication de la cirrhose et stables hémodynamiquement. Ainsi 76 malades inclus : 6.8% avaient une insuffisance surrénale selon les dosages du cortisol salivaire, 30.3% avaient des dosages du cortisol plasmatique anormaux (p=0.0006). Une albuminémie basse était le seul facteur de risque de discordance entre les 2 tests. Les facteurs de risque d insuffisance surrénale étaient un score de Child-Pugh élevé et une concentration en HDL basse. En conclusion, les dosages plasmatiques de cortisol surévaluent la prévalence de l insuffisance surrénale chez les malades cirrhotiques, principalement en raison de l hypoalbuminémie, et devraient être remplacés par les dosages du cortisol salivaire.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Etude du pronostic des malades cirrhotiques en choc septique

Cette thèse a permis de repréciser le pronostic actuel des malades cirrhotiques en réanimation, en particulier ceux en choc septique. Nous avons démontré que ce pronostic s est amélioré, y compris pour les malades en choc septique sous ventilation mécanique ou dialysés, les malades cirrhotiques ayant bénéficié des progrès de la réanimation constatés chez les malades de réanimation sans cirrhose. Nous avons également retrouvé que le pronostic des malades cirrhotiques en réanimation était beaucoup plus en rapport avec les défaillances d organes aiguës qu avec la gravité de la cirrhose sous-jacente. La revue de la littérature que nous avons effectuée retrouve des taux de mortalité, rapportés par les études les plus récentes, comparables aux nôtres. La plupart de ces études confirment que les scores de défaillance d organes prédisent mieux le pronostic que les scores généraux de réanimation et bien mieux que les scores spécifiques de cirrhose calculés le jour de l admission. Nous avons également retrouvé que, parmi les défaillances d organes, la défaillance de la coagulation évaluée par le taux de plaquettes par le score SOFA, n a pas d impact sur le pronostic des malades cirrhotiques en réanimation. De plus, ces défaillances d organes prédisent mieux le pronostic lorsqu elles sont évaluées au 3ème jour de réanimation. Concernant les malades en choc septique, nous avons retrouvé que les marbrures et la baisse de la StO2 au niveau du genou apparaissent plus tardivement chez les malades cirrhotiques qui vont décéder. Ces signes prédisent dès la 6ème heure la mortalité au 14ème jour avec une excellente spécificité mais une sensibilité faibleIn this manuscript, we reassessed the actual outcome of cirrhotic patients admitted to intensive care units, in particular in those with septic shock. We found that this outcome dramatically improved, including for patients with septic shock, placed under mechanical ventilation or receiving renal replacement therapy. We identified that the organ failures scores better predict the outcome than the liver-specific scores. We performed a review of literature; the most recent studies are in accordance with our results in term of mortality rates and in term of accuracy of the different scores to predict the outcome in these particular patients. We also identified that, among the different organ failures, the coagulation failure, defined by the platelet level according to the SOFA score, was not associated with a worse outcome. Moreover, the organ failures better predict the outcome when assessed 3 days after the admission to the intensive care unit. Regarding cirrhotic patients with septic shock, we demonstrated that mottling and the decrease in StO2 in the knee area appear later in patients with cirrhosis than in patients without. Those signs assessed 6 hours after the admission, predict the mortality at day 14 with an excellent specificity, but a relatively low sensibilityPARIS-BIUSJ-Biologie recherche (751052107) / SudocSudocFranceF