Gastrointestinal bleeding in critically ill immunocompromised patients

International audienceBackground Acute gastrointestinal bleeding (GIB) may be a severe condition in immunocompromised patients and may require intensive care unit (ICU) admission. We aimed to describe the clinical spectrum of critically ill immunocompromised patients with GIB and identify risk factors associated with mortality and severe GIB defined by hemorrhagic shock, hyperlactatemia and/or the transfusion of more than 5 red blood cells units. Finally, we compared this cohort with a control population of non-immunocompromised admitted in ICU for GIB. Results Retrospective study in 3 centers including immunocompromised patients with GIB admitted in ICU from January, 1st 2010 to December, 31rd 2019. Risk factors for mortality and severe GIB were assessed by logistic regression. Immunocompromised patients were matched with a control group of patients admitted in ICU with GIB. A total of 292 patients were analyzed in the study, including 141 immunocompromised patients (compared to a control group of 151 patients). Among immunocompromised patients, upper GIB was more frequent (73%) than lower GIB (27%). By multivariate analysis, severe GIB was associated with male gender (OR 4.48, CI95% 1.75–11.42, p = 0.00), upper GIB (OR 2.88, CI95% 1.11–7.46, p = 0.03) and digestive malignant infiltration (OR 5.85, CI95% 1.45–23.56, p = 0.01). Conversely, proton pump inhibitor treatment before hospitalization was significantly associated with decreased risk of severe GIB (OR 0.25, IC95% 0.10–0.65, p < 0.01). Fifty-four patients (38%) died within 90 days. By multivariate analysis, mortality was associated with hemorrhagic shock (OR 2.91, IC95% 1.33–6.38, p = 0 .01), upper GIB (OR 4.33, CI95% 1.50–12.47, p = 0.01), and long-term corticosteroid therapy before admission (OR 2.98, CI95% 1.32–6.71, p = 0.01). Albuminemia (per 5 g/l increase) was associated with lower mortality (OR 0.54, IC95% 0.35–0.84, p = 0.01). After matching with a control group of non-immunocompromised patients, severity of bleeding was increased in immunocompromised patients, but mortality was not different between the 2 groups. Conclusion Mortality is high in immunocompromised patients with GIB in ICU, especially in patients receiving long term corticosteroids. Mortality of GIB is not different from mortality of non-immunocompromised patients in ICU. The prophylactic administration of proton pump inhibitors should be considered in this population

Removal of totally implanted venous access ports for suspected infection in the intensive care unit: a multicenter observational study

International audienceBackground: While no data support this practice, international guidelines recommend the removal of totally implanted venous access ports (TIVAPs) in patients with suspicion of TIVAP-related bloodstream infection admitted in the intensive care unit (ICU) for a life-threatening sepsis.Methods: During this multicenter, retrospective and observational study, we included all patients admitted in five ICU for a life-threatening sepsis in whom a TIVAP was removed between January 2012 and December 2014. We aimed (1) at determining the proportion of confirmed TIVAP-related infections and (2) at assessing short- and long-term survival of patients with and without TIVAP-related infections.Results: One hundred and fifty-one patients (58 ± 14 years, 62% males) were included between 2012 and 2014. TIVAP-related infections were confirmed in 68 patients (45%). Demographic characteristics were similar between patients with and without TIVAP-related infections. SOFA score on admission per point increase [odd ratio (OR), 0.86 interval confidence (IC) 95% (0.8-0.9), p < 0.01] and local signs of infection [OR 4.0, IC 95% (1.1-15.6), p = 0.04] were significantly associated with TIVAP-related infection. Patients with TIVAP-related infection had lower ICU and 6-month mortality as compared to their counterparts (9 vs. 40%, respectively, p < 0.01; and 50 vs. 66%, respectively, p = 0.04). TIVAP-related infection was significantly associated with ICU survival [OR 0.2, IC 95% (0.05-0.5), p < 0.01].Conclusions: TIVAP-related infection was confirmed in nearly one out of two cases of life-threatening sepsis in patients in whom it has been removed. TIVAP-related infection was associated with a good prognosis, as compared to patients with other causes of infection

French ICU's health care workers have a poor knowledge of the cost of the devices they use for patient care: A prospective multicentric study

International audiencePurpose: ICU patient's care may require the use of onerous devices, which contributes to make this department one of the most expensive in the hospital. It seemed us relevant to assess healthcare workers' (HCWs) knowledge of the cost of the devices daily used in ICU.Materials and methods: An anonymous questionnaire was administered on a voluntary basis to HCWs of 3 ICUs.Measurements and main results: Cost estimations were expressed as percentage of the real cost; an estimation was considered correct if it was ±50% of the true price. 107 HCWs (66 physicians and 41 nurses and nurse aids) answered the survey. Only 29% of estimations were within 50% of the real cost. The prices of the cheapest devices were overestimated, while the costs of the most expensive ones were underestimated. In multivariate analysis, cost less than50 euros [OR = 3.2; CI 95%(1.6-6.3)], professional experience <10 years [OR = 1.5; CI 95%(1.1-2.1)], being a medical student [OR = 2.0; CI 95%(1.3-3.0)], and working in a university affiliated hospital [OR = 0.6; CI 95%(0.4-0.9)] were associated with an incorrect estimation.Conclusions: ICU's HCWs have a poor knowledge of the price of devices they regularly use for the care of their patients

Peripheral Tissue Hypoperfusion Predicts Post Intubation Hemodynamic Instability

International audienceBackground Tracheal intubation and invasive mechanical ventilation initiation is a procedure at high risk for arterial hypotension in intensive care unit. However, little is known about the relationship between pre-existing peripheral microvascular alteration and post-intubation hemodynamic instability (PIHI). Methods Prospective observational monocenter study conducted in an 18-bed medical ICU. Consecutive patients requiring tracheal intubation were eligible for the study. Global hemodynamic parameters (blood pressure, heart rate, cardiac function) and tissue perfusion parameters (arterial lactate, mottling score, capillary refill time [CRT], toe-to-room gradient temperature) were recorded before, 5~min and 2~h after tracheal intubation (TI). Post intubation hemodynamic instability (PIHI) was defined as any hemodynamic event requiring therapeutic intervention. Results During 1 year, 120 patients were included, mainly male (59%) with a median age of 68 [57\textendash 77]. The median SOFA score and SAPS II were 6 [4\textendash 9] and 47 [37\textendash 63], respectively. The main indications for tracheal intubation were hypoxemia (51%), hypercapnia (13%), and coma (29%). In addition, 48% of patients had sepsis and 16% septic shock. Fifty-one (42%) patients develop PIHI. Univariate analysis identified several baseline factors associated with PIHI, including norepinephrine prior to TI, sepsis, tachycardia, fever, higher SOFA and high SAPSII score, mottling score\,≥q\,3, high lactate level and prolonged knee CRT. By contrast, mean arterial pressure, baseline cardiac index, and ejection fraction were not different between PIHI and No-PIHI groups. After adjustment on potential confounders, the mottling score was associated with a higher risk for PIHI (adjusted OR: 1.84 [1.21\textendash 2.82] per 1 point increased; p \,=\,0.005). Among both global haemodynamics and tissue perfusion parameters, baseline mottling score was the best predictor of PIHI (AUC: 0.72 (CI 95% [0.62\textendash 0.81]). Conclusions In non-selected critically ill patients requiring invasive mechanical ventilation, tissue hypoperfusion parameters, especially the mottling score, could be helpful to predict PIHI

Removal of totally implanted venous access ports for suspected infection in the intensive care unit: a multicenter observational study

Abstract Background While no data support this practice, international guidelines recommend the removal of totally implanted venous access ports (TIVAPs) in patients with suspicion of TIVAP-related bloodstream infection admitted in the intensive care unit (ICU) for a life-threatening sepsis. Methods During this multicenter, retrospective and observational study, we included all patients admitted in five ICU for a life-threatening sepsis in whom a TIVAP was removed between January 2012 and December 2014. We aimed (1) at determining the proportion of confirmed TIVAP-related infections and (2) at assessing short- and long-term survival of patients with and without TIVAP-related infections. Results One hundred and fifty-one patients (58 ± 14 years, 62% males) were included between 2012 and 2014. TIVAP-related infections were confirmed in 68 patients (45%). Demographic characteristics were similar between patients with and without TIVAP-related infections. SOFA score on admission per point increase [odd ratio (OR), 0.86 interval confidence (IC) 95% (0.8–0.9), p < 0.01] and local signs of infection [OR 4.0, IC 95% (1.1–15.6), p = 0.04] were significantly associated with TIVAP-related infection. Patients with TIVAP-related infection had lower ICU and 6-month mortality as compared to their counterparts (9 vs. 40%, respectively, p < 0.01; and 50 vs. 66%, respectively, p = 0.04). TIVAP-related infection was significantly associated with ICU survival [OR 0.2, IC 95% (0.05–0.5), p < 0.01]. Conclusions TIVAP-related infection was confirmed in nearly one out of two cases of life-threatening sepsis in patients in whom it has been removed. TIVAP-related infection was associated with a good prognosis, as compared to patients with other causes of infection

Epidemiology of infective endocarditis in French intensive care units over the 1997–2014 period—from CUB-Réa Network

International audienceBACKGROUND: Few studies focus only on severe forms of infective endocarditis, for which organ failure requires admission to an intensive care unit (ICU). This study aimed to describe demographical, comorbidities, organ failure, and pathogen-related characteristics in a population of critically ill patients admitted to ICU for infective endocarditis and to identify risk factors of in-ICU mortality.METHODS: Retrospective observational multicenter (N = 34) study of the CUB-Rea register, based on ICD-10 coding rules, between 1997 and 2014 in France including ICU patients managed for infective endocarditis. In-ICU mortality associated factors were assessed by multivariate logistic regression including an interrupted time analysis of three periods (1997-2003, 2004-2009, and 2010-2014).RESULTS: Four thousand four hundred five patients admitted in ICU for infective endocarditis were included. We observed an increase in endocarditis prevalence, as well as an increase in organ failure severity over the three periods. In addition, valve surgery was more frequently performed (27%, 31%, and 42%, P < 0.0001) while in-ICU mortality significantly decreased (28%, 29%, and 23%, P < 0.001). Since 2010, a significant increase in the trends' slope of incidence for Streptococcus sp. and Staphylococcus sp. was observed with no change concerning intracellular bacteria, Enterococcus sp. or Candida sp. slope trends. In multivariate analysis, age, SAPS2, organ failure, stroke, and Staphylococcus sp. were associated with ICU mortality. Conversely, surgery, intracardiac devices, male gender, and Streptococcus sp.-related infective endocarditis were associated with a better outcome.CONCLUSIONS: Our study reveals a shifting landscape of infective endocarditis epidemiology in French ICUs, characterized by reduced in-ICU mortality despite higher severity, more surgery, and substantial changes in microbial epidemiology

Prediction of chronic kidney disease after acute kidney injury in ICU patients: study protocol for the PREDICT multicenter prospective observational study

International audienceAbstract Background Acute kidney injury (AKI) is frequent and associated with poor outcome in intensive care unit (ICU) patients. Besides the association with short- and long-term mortality, the increased risk of chronic kidney disease (CKD) has been recently highlighted in non-ICU patients. This study aims to describe the incidence and determinants of CKD after AKI and to develop a prediction score for CKD in ICU patients. Methods Prospective multicenter ( n = 17) observational study included 1200 ICU patients who suffered from AKI (defined by an AKIN stage ≥ 1) during their ICU stay and were discharged alive from ICU. Preexisting end-stage renal disease (ESRD) and immunosuppressant treatments are the main exclusion criteria. Patients will be monitored by a nephrologist at day 90 and every year for 3 years. The main outcome is the occurrence of CKD defined by a creatinine-based estimated glomerular filtration rate (eGFR) lower than 60 mL/min/1.73 m 2 or renal replacement therapy for ESRD in patients whose eGFR will be normalized (≥ 60 mL/min/1.73 m 2 ) at day 90. Secondary outcomes include albuminuria changes, eGFR decline slope and ESRD risk in patients with preexisting CKD, cardiovascular and thromboembolic events and health-related quality of life. Discussion This is the first study prospectively investigating kidney function evolution in ICU patients who suffered from AKI. Albuminuria and eGFR monitoring will allow to identify ICU patients at risk of CKD who may benefit from close surveillance after recovering from AKI. Major patient and AKI-related determinants will be tested to develop a prediction score for CKD in this population. Trial registration ClinicalTrials.gov, NCT03282409. Registered on September 14, 201

Additional file 1: of High-flow nasal oxygen vs. standard oxygen therapy in immunocompromised patients with acute respiratory failure: study protocol for a randomized controlled trial

SPIRIT 2013 Checklist: recommended items to address in a clinical trial protocol and related documents*. (PDF 142 kb