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

The role of anti-aquaporin 4 antibody in the conversion of acute brainstem syndrome to neuromyelitis optica

Background: Acute brainstem syndrome (ABS) may herald multiple sclerosis (MS), neuromyelitis optica (NMO), or occur as an isolated syndrome. The aquaporin 4 (AQP4)-specific serum autoantibody, NMO-IgG, is a biomarker for NMO. However, the role of anti-AQP4 antibody in the conversion of ABS to NMO is unclear. Methods: Thirty-one patients with first-event ABS were divided into two groups according to the presence of anti-AQP4 antibodies, their clinical features and outcomes were retrospectively analyzed. Results: Fourteen of 31 patients (45.16 %) were seropositive for NMO-IgG. The 71.43 % of anti-AQP4 (+) ABS patients converted to NMO, while only 11.76 % of anti-AQP4 (-) ABS patients progressed to NMO. Anti-AQP4 (+) ABS patients demonstrated a higher IgG index (0.68 ± 0.43 vs 0.42 ± 0.13, p < 0.01) and Kurtzke Expanded Disability Status Scale (4.64 ± 0.93 vs 2.56 ± 0.81, p < 0.01) than anti-AQP4 (-) ABS patients. Area postrema clinical brainstem symptoms occurred more frequently in anti-AQP4 (+) ABS patients than those in anti-AQP4 (-) ABS patients (71.43 % vs 17.65 %, p = 0.004). In examination of magnetic resonance imaging (MRI), the 78.57 % of anti-AQP4 (+) ABS patients had medulla-predominant involvements in the sagittal view and dorsal-predominant involvements in the axial view. Conclusions: ABS represents an inaugural or limited form of NMO in a high proportion of anti-AQP4 (+) patients

Year in review in Intensive Care Medicine 2009: II. Neurology, cardiovascular, experimental, pharmacology and sedation, communication and teaching

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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/)

Etude des propriétés mécaniques des cellules épithéliales alvéolaires dans le SDRA par la technique de magnétocytométrie

Le SDRA se définit par une atteinte inflammatoire intense localisée au poumon, sa principale caractéristique mécanique étant une baisse de la compliance. Le traitement repose sur la ventilation mécanique, qui peut aggraver les lésions préexistantes. Nous avons étudié les interactions entre contrainte mécanique et médiateurs inflammatoires à la phase aiguë du SDRA. La magnécytométrie permet de générer un stress mécanique sur des cellules épithéliales alvéolaires humaines (A549) en culture et d'en mesurer certaines propriétés mécaniques (rigidité globale et des compartiments cortical et profond du cytosquelette). Le LBA est prélevé chez des patients atteints de SDRA et chez des sujets atteints d'OAP dans les 24 premières heures. Les cellules sont exposées à du surnageant de LBA-SDRA, LBA-OAP, à du TNFa ou à de l'IL1-b. Le marquage de l'actine, dans les mêmes conditions, permet d'étudier la formation de fibres de stress. L'utilisation de cytochalasine D permet d'analyser l'effet sur la rigidité après dépolymérisation des fibres d'actine. La rigidité globale et des deux compartiments du cytosquelette est significativement augmentée dans le groupe SDRA par rapport au groupe OAP. Cette augmentation de rigidité est associée à la formation de fibres de stress et est diminuée après dépolymérisation de l'actine par la cytochalasine D. Ni le TNFa ni l'IL1-b n'induisent de modification des propriétés mécaniques du cytosquelette. Nous avons trouvé une majoration de la rigidité du cytosquelette des cellules épithéliales alvéolaires exposées à un environnement reproduisant le SDRA, montrant pour la première fois une altération des propriétés mécaniques au niveau cellulaireARDS is defined by an intense inflammation localized to the lung and is characterized by an increased lung elastance. Treatment relies on mechanical ventilation, which can worsen pre-existing lesions. We studied the interactions between mechanical strain and inflammatory mediators at the acute phase of ARDS. Magnetic twisting cytometry allows to generate a mechanical stress on cultured human alveolar epithelial cells (A549) and to measure some of their mechanical properties (global cytoskeleton stiffness, cortical and cytosolic cytoskeleton components stiffness). Bronchoalveolar lavage samples are performed in patients suffering either from ARDS or hydrostatic lung edema within the first 24 hours. Cells are exposed to supernatant of ARDS-BAL, HLE-BAL, TNFa or IL1-b. Actin immunostaining, in the same conditions, permits to study stress fibers formation. Cytochalasin D allows to analyze the effect of actin depolymerisation on cytoskeleton stiffness. Both global and each cytoskeleton components stiffness are significantly increased in ARDS group compared to HLE group. This effect is associated to a stress fibers formation and is decreased after actin depolymerisation by cytochalasin D. Neither TNFa nor IL1-b induces cytoskeleton mechanical properties modifications. We found an increase of cytoskeleton stiffness in alveolar epithelial cells exposed to an inflammatory environment mimicking ARDS, showing for the first time mechanical properties alterations at the cellular levelPARIS12-CRETEIL BU Médecine (940282101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Postoperative peritonitis without an underlying digestive fistula after complete cytoreductive surgery plus HIPEC

Background/Aim: Peritoneal carcinomatosis (PC) is a pernicious event associated with a dismal prognosis. Complete cytoreductive surgery (CCRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is able to yield an important survival benefit but at the price of a risky procedure inducing potentially severe complications. Postoperative peritonitis after abdominal surgery occurs mostly when the digestive lumen and the peritoneum communicate but in rare situation, no underlying digestive fistula can be found. The aim of this study was to report this situation after CCRS plus HIPEC, which has not been described yet and for which the treatment is not yet well defined. Patients and Methods: Between 1994 and 2012, 607 patients underwent CCRS plus HIPEC in our tertiary care center and were retrospectively analyzed. Results: Among 52 patients (9%) reoperated for postoperative peritonitis, no digestive fistula was found in seven (1%). All had a malignant peritoneal pseudomyxoma with an extensive disease (median Peritoneal Cancer Index: 27). The median interval between surgery and reoperation was 8 days [range: 3-25]. Postoperative mortality was 14%. Five different bacteriological species were identified in intraoperative samples, most frequently Escherichia coli (71%). The infection was monobacterial in 71%, with multidrug resistant germs in 78%. Conclusions: Postoperative peritonitis without underlying fistula after CCRS plus HIPEC is a rare entity probably related to bacterial translocation, which occurs in patients with extensive peritoneal disease requiring aggressive surgeries. The principles of treatment do not differ from that of other types of postoperative peritonitis