Ann Intensive Care

Unlike for septic shock, there are no specific international recommendations regarding the management of cardiogenic shock (CS) in critically ill patients. We present herein recommendations for the management of cardiogenic shock in adults, developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF)), with the participation the French Society of Anesthesia and Intensive Care (SFAR), the French Cardiology Society (SFC), the French Emergency Medicine Society (SFMU), and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV). The recommendations cover 15 fields of application such as: epidemiology, myocardial infarction, monitoring, vasoactive drugs, prehospital care, cardiac arrest, mechanical assistance, general treatments, cardiac surgery, poisoning, cardiogenic shock complicating end-stage cardiac failure, post-shock treatment, various etiologies, and medical care pathway. The experts highlight the fact that CS is a rare disease, the management of which requires a multidisciplinary technical platform as well as specialized and experienced medical teams. In particular, each expert center must be able to provide, at the same site, skills in a variety of disciplines, including medical and interventional cardiology, anesthesia, thoracic and vascular surgery, intensive care, cardiac assistance, radiology including for interventional vascular procedures, and a circulatory support mobile unit

Epinephrine and short-term survival in cardiogenic shock : an individual data meta-analysis of 2583 patients

Correction Volume: 44 Issue: 11 Pages: 2022-2023 DOI: 10.1007/s00134-018-5372-9Catecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients. We performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality. Fourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17-76%) and short-term mortality rate was 49% (21-69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8-3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4-6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0-6.0]). In this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.Peer reviewe

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions

Identification des profils congestifs de l'insuffisance cardiaque aiguë pour guider les stratégies diagnostiques et thérapeutiques de prise en charge en urgence

Acute dyspnea due to pulmonary congestion in acute heart failure (AHF) is a common reason for admission to the ER. Currently, AHF is twice as common and associated with a twofold higher risk of death (8%) than acute coronary syndromes (ACS). Pre-hospital and emergency care has become the cornerstone of care of these patients. In recent years, new paradigms have emerged surrounding AHF management, highlighting the complexity of this disease. Hence the use of the term acute heart failure syndrome (AHFS), a terminology underscoring the plurality of clinical situations and the diversity of congestive profiles. However, the assessment of congestion distribution during an AHFS is currently predominantly based on clinical arguments in spite of limited data. Alternatively, lung ultrasound (LUS) and estimation of plasma volume (ePVS, based on hemoglobin and hematocrit) could allow for a better assessment of congestive profiles. Several studies report that the rapid and accurate etiological diagnosis of acute dyspnea is associated with prognosis. Despite the availability of diagnostic tools including clinical exam, biomarkers and radiology, there is still considerable uncertainty regarding etiological diagnosis in the emergency department (ED) setting, hence rendering it difficult in reducing the « Time to therapy » advocated by the recommendations of the European Cardiology Society 2016 for AHF. The objectives of the present work were to identify distinct congestion profiles of AHF, to clarify the diagnostic and prognostic value of these profiles in the context of acute dyspnea, and to determine whether the therapeutic effect of initial emergency management modalities is dependent on these congestive profiles. In the course of our work, we were able to demonstrate in the DeFSSICA cohort that the tools allowing a better assessment of the patient's congestive profile (particularly LUS and ePVS) are rarely used in ED. In a second study, we showed in the PARADISE cohort (NCT02800122) - designed as part of this PhD research project - that impaired renal function, hyponatremia and dysglycemia are significantly associated with prognosis in patients with acute dyspnea. In a third study, we showed that the ePVS is an effective AHF diagnostic tool and that a higher congestion level assessed by ePVS is associated with higher in-hospital mortality of patients admitted for acute dyspnea. Our work also enabled us to design and initiate the PURPLE (Pathway and Urgent caRe of dyspneic Patients at the emergency department in LorrainE district - NCT03194243) study, which collects clinical and paraclinical data of patients admitted for acute dyspnea on a prospective basis. Lastly, this PhD research project enabled designing and obtain funding for the EMERALD-US project (Evaluation of the feasibility of implementing and performance of an Emergency Echography algorithm for the diagnosis of Acute Dyspnea-UltraSound) which aims to validate an original algorithm specific to emergency situations using lung, cardiac and vascular ultrasound for the etiological diagnosis of acute dyspneaLa dyspnée aigue due à une congestion pulmonaire dans le cadre d’une insuffisance cardiaque aiguë (ICA) est un motif d’admission fréquent aux Urgences. Actuellement, l’ICA est deux fois plus fréquente et est associée à un risque deux fois plus élevé de décès (8%) que les syndromes coronariens aigus (SCA). La prise en charge en pré hospitalier et aux urgences est devenue une étape clé du parcours de soin de ces patients. Ces dernières années ont vu émerger de nouveaux paradigmes autour de la prise en charge de l’ICA mettant en perspective la complexité de cette pathologie. On parle désormais de syndrome d’insuffisance cardiaque aiguë (SICA), terminologie qui souligne la pluralité des situations cliniques et la diversité des profils congestifs. Cependant, l’évaluation de la répartition de la congestion au cours d’un SICA, même s’il existe peu de données sur ce sujet, est actuellement principalement faite sur des arguments cliniques ; l’échographie pulmonaire et l’estimation du volume plasmatique (ePVS, basé sur un calcul intégrant hémoglobine et hématocrite) pourraient permettre de mieux préciser les profils congestifs. Plusieurs études rapportent que la rapidité et l’exactitude du diagnostic étiologique de dyspnée aigue sont associées au pronostic des patients. Malgré l’existence d’outils diagnostiques (biomarqueurs, examens de radiologie), l’incertitude quant au diagnostic étiologique reste importante dans le contexte d’un service d’urgence, ce qui rend difficile la diminution du « Time to therapy » promue par les recommandations de la société européenne de cardiologie 2016. Les objectifs de notre travail étaient d’identifier des profils de congestion distincts d’insuffisance cardiaque aigue, de préciser la valeur diagnostique et pronostique de ces profils dans le contexte d’une dyspnée aigue, et de déterminer si l’effet thérapeutique des modalités de prise en charge initiale en urgence est dépendant de ces profils congestifs. Dans le cadre de notre travail, nous avons pu montrer sur la base des analyses réalisées dans la cohorte DeFSSICA que les outils permettant de mieux préciser le profil congestif des patients (notamment l’échographie pulmonaire et l’ePVS) sont peu utilisés aux urgences. Dans un deuxième travail, nous avons montré sur la cohorte PARADISE (NCT02800122) – conçue dans le cadre de ce doctorat, que l’altération de fonction rénale, l’hyponatrémie et la dysglycémie sont associée de façon significative au pronostic des patients atteints de dyspnée aigue. Dans un troisième travail, nous avons montré que le volume plasmatique estimé est un outil diagnostique performant de SICA et qu’un niveau plus important de congestion évaluée par l’ePVS est associé à une mortalité intra-hospitalière des patients admis pour dyspnée aigue plus élevée. Notre travail a aussi permis de concevoir et démarrer l’étude PURPLE (Pathway and Urgent caRe of dyspneic Patient at the emergency department in LorrainE district – NCT NCT03194243) qui collecte les données cliniques et paracliniques des patients admis pour dyspnée aigue aux urgences de façon prospective dans la région Lorraine. Par ailleurs, ce travail de thèse a aussi permis de concevoir et faire financer le projet EMERALD-US (Evaluation de la faisabilité de la Mise en œuvre et de la performance d’un algorithme d’EchogRraphie Aux urgences pour Le diagnostic de Dyspnée aigue-UltraSound) qui vise à valider un algorithme spécifique aux urgences utilisant l’échographie pulmonaire, cardiaque et vasculaire pour le diagnostic étiologique de dyspnée aigu

Identification of acute heart failure congestive profiles to guide diagnostic and therapeutic strategies for emergency management

La dyspnée aigue due à une congestion pulmonaire dans le cadre d’une insuffisance cardiaque aiguë (ICA) est un motif d’admission fréquent aux Urgences. Actuellement, l’ICA est deux fois plus fréquente et est associée à un risque deux fois plus élevé de décès (8%) que les syndromes coronariens aigus (SCA). La prise en charge en pré hospitalier et aux urgences est devenue une étape clé du parcours de soin de ces patients. Ces dernières années ont vu émerger de nouveaux paradigmes autour de la prise en charge de l’ICA mettant en perspective la complexité de cette pathologie. On parle désormais de syndrome d’insuffisance cardiaque aiguë (SICA), terminologie qui souligne la pluralité des situations cliniques et la diversité des profils congestifs. Cependant, l’évaluation de la répartition de la congestion au cours d’un SICA, même s’il existe peu de données sur ce sujet, est actuellement principalement faite sur des arguments cliniques ; l’échographie pulmonaire et l’estimation du volume plasmatique (ePVS, basé sur un calcul intégrant hémoglobine et hématocrite) pourraient permettre de mieux préciser les profils congestifs. Plusieurs études rapportent que la rapidité et l’exactitude du diagnostic étiologique de dyspnée aigue sont associées au pronostic des patients. Malgré l’existence d’outils diagnostiques (biomarqueurs, examens de radiologie), l’incertitude quant au diagnostic étiologique reste importante dans le contexte d’un service d’urgence, ce qui rend difficile la diminution du « Time to therapy » promue par les recommandations de la société européenne de cardiologie 2016. Les objectifs de notre travail étaient d’identifier des profils de congestion distincts d’insuffisance cardiaque aigue, de préciser la valeur diagnostique et pronostique de ces profils dans le contexte d’une dyspnée aigue, et de déterminer si l’effet thérapeutique des modalités de prise en charge initiale en urgence est dépendant de ces profils congestifs. Dans le cadre de notre travail, nous avons pu montrer sur la base des analyses réalisées dans la cohorte DeFSSICA que les outils permettant de mieux préciser le profil congestif des patients (notamment l’échographie pulmonaire et l’ePVS) sont peu utilisés aux urgences. Dans un deuxième travail, nous avons montré sur la cohorte PARADISE (NCT02800122) – conçue dans le cadre de ce doctorat, que l’altération de fonction rénale, l’hyponatrémie et la dysglycémie sont associée de façon significative au pronostic des patients atteints de dyspnée aigue. Dans un troisième travail, nous avons montré que le volume plasmatique estimé est un outil diagnostique performant de SICA et qu’un niveau plus important de congestion évaluée par l’ePVS est associé à une mortalité intra-hospitalière des patients admis pour dyspnée aigue plus élevée. Notre travail a aussi permis de concevoir et démarrer l’étude PURPLE (Pathway and Urgent caRe of dyspneic Patient at the emergency department in LorrainE district – NCT NCT03194243) qui collecte les données cliniques et paracliniques des patients admis pour dyspnée aigue aux urgences de façon prospective dans la région Lorraine. Par ailleurs, ce travail de thèse a aussi permis de concevoir et faire financer le projet EMERALD-US (Evaluation de la faisabilité de la Mise en œuvre et de la performance d’un algorithme d’EchogRraphie Aux urgences pour Le diagnostic de Dyspnée aigue-UltraSound) qui vise à valider un algorithme spécifique aux urgences utilisant l’échographie pulmonaire, cardiaque et vasculaire pour le diagnostic étiologique de dyspnée aigueAcute dyspnea due to pulmonary congestion in acute heart failure (AHF) is a common reason for admission to the ER. Currently, AHF is twice as common and associated with a twofold higher risk of death (8%) than acute coronary syndromes (ACS). Pre-hospital and emergency care has become the cornerstone of care of these patients. In recent years, new paradigms have emerged surrounding AHF management, highlighting the complexity of this disease. Hence the use of the term acute heart failure syndrome (AHFS), a terminology underscoring the plurality of clinical situations and the diversity of congestive profiles. However, the assessment of congestion distribution during an AHFS is currently predominantly based on clinical arguments in spite of limited data. Alternatively, lung ultrasound (LUS) and estimation of plasma volume (ePVS, based on hemoglobin and hematocrit) could allow for a better assessment of congestive profiles. Several studies report that the rapid and accurate etiological diagnosis of acute dyspnea is associated with prognosis. Despite the availability of diagnostic tools including clinical exam, biomarkers and radiology, there is still considerable uncertainty regarding etiological diagnosis in the emergency department (ED) setting, hence rendering it difficult in reducing the « Time to therapy » advocated by the recommendations of the European Cardiology Society 2016 for AHF. The objectives of the present work were to identify distinct congestion profiles of AHF, to clarify the diagnostic and prognostic value of these profiles in the context of acute dyspnea, and to determine whether the therapeutic effect of initial emergency management modalities is dependent on these congestive profiles. In the course of our work, we were able to demonstrate in the DeFSSICA cohort that the tools allowing a better assessment of the patient's congestive profile (particularly LUS and ePVS) are rarely used in ED. In a second study, we showed in the PARADISE cohort (NCT02800122) - designed as part of this PhD research project - that impaired renal function, hyponatremia and dysglycemia are significantly associated with prognosis in patients with acute dyspnea. In a third study, we showed that the ePVS is an effective AHF diagnostic tool and that a higher congestion level assessed by ePVS is associated with higher in-hospital mortality of patients admitted for acute dyspnea. Our work also enabled us to design and initiate the PURPLE (Pathway and Urgent caRe of dyspneic Patients at the emergency department in LorrainE district - NCT03194243) study, which collects clinical and paraclinical data of patients admitted for acute dyspnea on a prospective basis. Lastly, this PhD research project enabled designing and obtain funding for the EMERALD-US project (Evaluation of the feasibility of implementing and performance of an Emergency Echography algorithm for the diagnosis of Acute Dyspnea-UltraSound) which aims to validate an original algorithm specific to emergency situations using lung, cardiac and vascular ultrasound for the etiological diagnosis of acute dyspne

L'angioplastie facilitée par l'administration préhospitalière d'abciximab dans la prise en charge de l'infarctus du myocarde au SAMU 54

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Lung ultrasound - The extension of clinical examination in patients with acute heart failure: Reply

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Collateral damage of the COVID-19 outbreak: expression of concern

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Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review

Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure

Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review

Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure