Passive leg raising can predict fluid responsiveness in patients placed on venovenous extracorporeal membrane oxygenation

International audienceABSTRACT: INTRODUCTION: In ICUs, fluid administration is frequently used to treat hypovolaemia. Because volume expansion (VE) can worsen acute respiratory distress syndrome (ARDS) and volume overload must be avoided, predictive indicators of fluid responsiveness are needed. The purpose of this study was to determine whether passive leg raising (PLR) can be used to predict fluid responsiveness in patients with ARDS treated with venovenous extracorporeal membrane oxygenation (ECMO). METHODS: We carried out a prospective study in a university hospital surgical ICU. All patients with ARDS treated with venovenous ECMO and exhibiting clinical and laboratory signs of hypovolaemia were enrolled. We measured PLR-induced changes in stroke volume (ΔPLRSV) and cardiac output (ΔPLRCO) using transthoracic echocardiography. We also assessed PLR-induced changes in ECMO pump flow (ΔPLRPO) and PLR-induced changes in ECMO pulse pressure (ΔPLRPP) as predictors of fluid responsiveness. Responders were defined by an increase in stroke volume (SV) > 15% after VE. RESULTS: Twenty-five measurements were obtained from seventeen patients. In 52% of the measurements (n = 13), SV increased by > 15% after VE (responders). The patients' clinical characteristics appeared to be similar between responders and nonresponders. In the responder group, PLR significantly increased SV, cardiac output and pump flow (P 10% ΔPLRSV may predict fluid responsiveness. ΔPLRPP and ΔPLRPO cannot predict fluid responsiveness

Prognostic value of right ventricular dilatation on computed tomography pulmonary angiogram for predicting adverse clinical events in severe COVID-19 pneumonia

BackgroundRight ventricle dilatation (RVD) is a common complication of non-intubated COVID-19 pneumonia caused by pro-thrombotic pneumonitis, intra-pulmonary shunting, and pulmonary vascular dysfunction. In several pulmonary diseases, RVD is routinely measured on computed tomography pulmonary angiogram (CTPA) by the right ventricle-to-left ventricle (LV) diameter ratio > 1 for predicting adverse events.ObjectiveThe aim of the study was to evaluate the association between RVD and the occurrence of adverse events in a cohort of critically ill non-intubated COVID-19 patients.MethodsBetween February 2020 and February 2022, non-intubated patients admitted to the Amiens University Hospital intensive care unit for COVID-19 pneumonia with CTPA performed within 48 h of admission were included. RVD was defined by an RV/LV diameter ratio greater than one measured on CTPA. The primary outcome was the occurrence of an adverse event (renal replacement therapy, extracorporeal membrane oxygenation, 30-day mortality after ICU admission).ResultsAmong 181 patients, 62% (n = 112/181) presented RVD. The RV/LV ratio was 1.10 [1.05–1.18] in the RVD group and 0.88 [0.84–0.96] in the non-RVD group (p = 0.001). Adverse clinical events were 30% and identical in the two groups (p = 0.73). In Receiving operative curves (ROC) analysis, the RV/LV ratio measurement failed to identify patients with adverse events. On multivariable Cox analysis, RVD was not associated with adverse events to the contrary to chest tomography severity score > 10 (hazards ratio = 1.70, 95% CI [1.03–2.94]; p = 0.04) and cardiovascular component (> 2) of the SOFA score (HR = 2.93, 95% CI [1.44–5.95], p = 0.003).ConclusionRight ventricle (RV) dilatation assessed by RV/LV ratio was a common CTPA finding in non-intubated critical patients with COVID-19 pneumonia and was not associated with the occurrence of clinical adverse events

ECMO for COVID-19 patients in Europe and Israel

Since March 15th, 2020, 177 centres from Europe and Israel have joined the study, routinely reporting on the ECMO support they provide to COVID-19 patients. The mean annual number of cases treated with ECMO in the participating centres before the pandemic (2019) was 55. The number of COVID-19 patients has increased rapidly each week reaching 1531 treated patients as of September 14th. The greatest number of cases has been reported from France (n = 385), UK (n = 193), Germany (n = 176), Spain (n = 166), and Italy (n = 136) .The mean age of treated patients was 52.6 years (range 16–80), 79% were male. The ECMO configuration used was VV in 91% of cases, VA in 5% and other in 4%. The mean PaO2 before ECMO implantation was 65 mmHg. The mean duration of ECMO support thus far has been 18 days and the mean ICU length of stay of these patients was 33 days. As of the 14th September, overall 841 patients have been weaned from ECMO support, 601 died during ECMO support, 71 died after withdrawal of ECMO, 79 are still receiving ECMO support and for 10 patients status n.a. . Our preliminary data suggest that patients placed on ECMO with severe refractory respiratory or cardiac failure secondary to COVID-19 have a reasonable (55%) chance of survival. Further extensive data analysis is expected to provide invaluable information on the demographics, severity of illness, indications and different ECMO management strategies in these patients

Analgésie postopératoire par infiltration de ropivacaïne après sternotomie en chirurgie cardiaque (étude de faisabilité)

AMIENS-BU Santé (800212102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

French ICUs fight back: An example of regional ICU organisation to tackle the SARS-CoV-2 outbreak

International audienc

Hemodynamic impact of molecular adsorbent recirculating system in refractory vasoplegic shock due to calcium channel blocker poisoning

International audienceObjective: To report the hemodynamic effect of to the molecular adsorbent recirculating system (MARS (TM)) therapy for patients in refractory vasoplegic shock due to calcium channel blocker (CCB) poisoning Methods: We report a retrospective cohort of patients who were hospitalized for CCB poisoning with refractory vasoplegic shock and treated by MARS therapy, at Amiens Hospital University, from January 2010 to December 2019. Improvement in hemodynamic was assessed by dynamic changes in mean arterial pressure (MAP) and norepinephrine levels over a 24-h period after MARS therapy. Cardiac function was assessed by transthoracic echocardiography. Results: MARS therapy was performed on seven patients for CCB poisoning. CCB poisoning included nicardipine (n = 3, 43%) amlodipine (n = 3, 43%), and verapamil (n = 1, 14%). The median time to start MARS therapy was 24 [14-27] h after drug ingestion and 6 [2-9] h after ICU admission. Cardiac output was preserved for all patients. MAP values improved from 56 [43-58] to 65 [61-78] 16 mmHg (p = 0.005). Norepinephrine dose significantly decreased from 3.2 [0.8-10] mu g/kg/min to 1.2 [0.1-1.9] mu g/kg/min (p = 0.008) and lactate level decreased from 3.2 [2.4-3.4] mmol/l(-1) to 1.6 [0.9-2.2] mmol/l(-1) (p = 0.008). The median length of ICU stay was 4 (2-7) days and hospital stay was 4 (4-16) days. No complication related to the MARS therapy were reported. No patient died and all were discharged from the hospital. Conclusion: We reported the largest case-series of MARS therapy for refractory vasoplegic shock due to CCB poisoning. We observed that MARS therapy was associated with an improvement of hemodynamic parameters

Extracorporeal membrane oxygenation for respiratory failure in COVID-19 patients: outcome and time-course of clinical and biological parameters

International audienc

Central venous-to-arterial CO2 difference is a poor tool to predict adverse outcomes after cardiac surgery: a retrospective study

International audiencePurpose The venous-to-arterial carbon dioxide partial pressure difference (CO2 gap) has been reported to be a sensitive indicator of cardiac output adequacy. We aimed to assess whether the CO2 gap can predict postoperative adverse outcomes after cardiac surgery. Methods A retrospective study was conducted of 5,151 patients from our departmental database who underwent cardiac surgery from 1 January 2008 to 31 December 2018. Lactate level (mmol center dot L-1), central venous oxygen saturation (ScVO2) (%), and the venous-to-arterial carbon dioxide difference (CO2 gap) were measured at intensive care unit (ICU) admission and on days 1 and 2 after cardiac surgery. The following postoperative adverse outcomes were collected: ICU mortality, hemopericardium or tamponade, resuscitated cardiac arrest, acute kidney injury, major bleeding, acute hepatic failure, mesenteric ischemia, and pneumonia. The primary outcome was the presence of at least one postoperative adverse outcome. Logistic regression was used to assess the association between ScVO2, lactate, and the CO2 gap with adverse outcomes. Their diagnostic performance was compared using a receiver operating characteristic (ROC) curve. Results There were 1,933 patients (38%) with an adverse outcome. Cardiopulmonary bypass (CPB) parameters were similar between groups. The CO2 gap was slightly higher for the ``adverse outcomes'' group than for the ``no adverse outcomes'' group. Arterial lactate at admission, day 1, and day 2 was also slightly higher in patients with adverse outcomes. Central venous oxygen saturation was not significantly different between patients with and without adverse outcomes. The area under the ROC curve to predict outcomes after CPB for the CO2 gap at admission, day 1, and day 2 were 0.52, 0.55, and 0.53, respectively. Conclusion After cardiac surgery with CPB, the CO2 gap at ICU admission, day 1, and day 2 was associated with postoperative adverse outcomes but showed poor diagnostic performance