Hemodynamic Changes during a Deep Inspiration Maneuver Predict Fluid Responsiveness in Spontaneously Breathing Patients

Objective. We hypothesized that the hemodynamic response to a deep inspiration maneuver (DIM) indicates fluid responsiveness in spontaneously breathing (SB) patients. Design. Prospective study. Setting. ICU of a general hospital. Patients. Consecutive nonintubated patients without mechanical ventilation, considered for volume expansion (VE). Intervention. We assessed hemodynamic status at baseline and after VE. Measurements and Main Results. We measured radial pulse pressure (PP) using an arterial catheter and peak velocity of femoral artery flow (VF) using continuous Doppler. Changes in PP and VF induced by a DIM (ΔPPdim and ΔVFdim) were calculated in 23 patients. ΔPPdim and ΔVFdim ≥12% predicted responders to VE with sensitivity of 90% and specificity of 100%. Conclusions. In a restricted population of SB patients with severe sepsis or acute pancreatitis, ΔPPdim and ΔVFdim are accurate indices for predicting fluid responsiveness. These results should be confirmed in a larger population before validating their use in current practice

Intensive care unit-acquired Stenotrophomonas maltophilia: incidence, risk factors, and outcome

INTRODUCTION: The aim of this study was to determine incidence, risk factors, and impact on outcome of intensive care unit (ICU)-acquired Stenotrophomonas maltophilia. METHODS: This prospective observational case-control study, which was a part of a cohort study, was conducted in a 30-bed ICU during a three year period. All immunocompetent patients hospitalised >48 hours were eligible. Patients with non-fermenting Gram-negative bacilli (NF-GNB) at ICU admission were excluded. Patients without ICU-acquired S. maltophilia who developed an ICU-acquired NF-GNB other than S. maltophilia were also excluded. Screening (tracheal aspirate and skin, anal, and nasal swabs) for NF-GNB was performed in all patients at ICU admission and weekly. Univariate and multivariate analyses were performed to determine risk factors for ICU-acquired S. maltophilia and for ICU mortality. RESULTS: Thirty-eight (2%) patients developed an S. maltophilia ICU-acquired colonisation and/or infection and were all successfully matched with 76 controls. Chronic obstructive pulmonary disease (COPD) and duration of antibiotic treatment (odds ratio [OR] [95% confidence interval (CI)] = 9.4 [3 to 29], p < 0.001, and 1.4 [1 to 2.3], p = 0.001, respectively) were independently associated with ICU-acquired S. maltophilia. Mortality rate (60% versus 40%, OR [95% CI] = 1.3 [1 to 1.7, p = 0.037]), duration of mechanical ventilation (23 ± 16 versus 7 ± 11 days, p < 0.001), and duration of ICU stay (29 ± 21 versus 15 ± 17 days, p < 0.001) were significantly higher in cases than in controls. In addition, ICU-acquired infection related to S. maltophilia was independently associated with ICU mortality (OR [95% CI] = 2.8 [1 to 7.7], p = 0.044). CONCLUSION: COPD and duration of antibiotic treatment are independent risk factors for ICU-acquired S. maltophilia. ICU-acquired S. maltophilia is associated with increased morbidity and mortality rates. ICU-acquired infection related to S. maltophilia is an independent risk factor for ICU 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

Présentation des résultats de l'étude P2IPER (pratique et perception des indicateurs prédictifs de l'efficacité du remplissage vasculaire en réanimation)

Le remplissage vasculaire est une thérapeutique fréquemment employée chez le patient en sepsis. De nombreux indicateurs prédictifs de l effet du remplissage vasculaire ont été développés afin d optimiser son administration. Certains indicateurs ne peuvent être utilisés de façon usuelle du fait de nombreuses limitations. Notre étude prospective observationnelle multicentrique s est intéressée à leur utilisation réelle et déclarée en nous appuyant sur les données du champ 2 de la conférence de Consensus de 2006, particulièrement à celles recommandant de ne pas utiliser les indicateurs dynamiques en routine. 77,3% des médecins déclarent utiliser les indicateurs dynamiques dans plus de la moitié des remplissages vasculaires qu ils prescrivent, la pratique retrouve leur utilisation dans 29,4% des remplissages vasculaires. Tous les indicateurs ont été beaucoup moins employé que ce qui était attendu après les déclarations des médecins prescripteurs. Par ailleurs, les indicateurs étaient dans l ensemble peu employés quand les conditions nécessaires à leur utilisation étaient réunies, excepté pour les indicateurs VPP et VVS, ceux-ci ayant été trop fréquemment utilisés si on respecte leurs limites usuelles d utilisation. Si l adhésion aux recommandations de la conférence de consensus était bonne quel que soit l hôpital d adhésion (CHU ou CHG) ou le grade du praticien, l utilisation des différents indicateurs était elle variable selon le centre et l expérience du praticien. Les indicateurs prédictifs de réponse au remplissage vasculaire font partie intégrante de la prise en charge des patients de réanimation, au sein d un algorithme de prise en charge. Leur analyse s avère délicate sortie du contexte de la prescriptionLILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Influence d'une formation ciblée concernant les limitations et/ou arrêts des traitements sur le vécu du personnel paramédical en réanimation (étude prospective monocentrique)

LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Etude de la déformation du ventricule droit défaillant par échocardiographie (faisabilité et apports diagnostiques)

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Accuracy of alpha amylase in diagnosing microaspiration in intubated critically-ill patients.

Amylase concentration in respiratory secretions was reported to be a potentially useful marker for aspiration and pneumonia. The aim of this study was to determine accuracy of α-amylase in diagnosing microaspiration in critically ill patients.Retrospective analysis of prospectively collected data collected in a medical ICU. All patients requiring mechanical ventilation for at least 48 h, and included in a previous randomized controlled trial were eligible for this study, provided that at least one tracheal aspirate was available for α-amylase measurement. As part of the initial trial, pepsin was quantitatively measured in all tracheal aspirates during a 48-h period. All tracheal aspirates were frozen, allowing subsequent measurement of α-amylase for the purpose of the current study. Microaspiration was defined as the presence of at least one positive tracheal aspirate for pepsin (>200 ng.mL-1). Abundant microaspiration was defined as the presence of pepsin at significant level in >74% of tracheal aspirates.Amylase was measured in 1055 tracheal aspirates, collected from 109 patients. Using mean α-amylase level per patient, accuracy of α-amylase in diagnosing microaspiration was moderate (area under the receiver operator curve 0.72±0.05 [95%CI 0.61-0.83], for an α-amylase value of 1685 UI.L-1). However, when α-amylase levels, coming from all samples, were taken into account, area under the receiver operator curve was 0.56±0.05 [0.53-0.60]. Mean α-amylase level, and percentage of tracheal aspirates positive for α-amylase were significantly higher in patients with microaspiration, and in patients with abundant microaspiration compared with those with no microaspiration; and similar in patients with microaspiration compared with those with abundant microaspiration. α-amylase and pepsin were significantly correlated (r2 = 0.305, p = 0.001).Accuracy of mean α-amylase in diagnosing microaspiration is moderate. Further, when all α-amylase levels were taken into account, α-amylase was inaccurate in diagnosing microaspiration, compared with pepsin

Patient characteristics during ICU stay.

<p>Data are n (%) or median (interquartile range).</p><p>LOD: logistic organ dysfunction; Pcuff: cuff pressure; ACV: assist control ventilation, PSV: pressure support ventilation.</p