Evaluation du taux de carnitine plasmatique à l'admission en réanimation de l'insuffisant respiratoire chronique (IRC) en décomposition aiguë

Objectif: Evaluer le taux de la carnitine et de ses dérivés à l admission en réanimation des patients ayant une IRC en décompensation aiguë, et rechercher un lien éventuel entre les valeurs initiales de carnitine, l état nutritionnel, le SAO et la morbi-mortalité. Patients et méthodes: étude prospective, monocentrique, menée sur 22 mois. Tous les patients admis en réanimation pour décompensation aiguë d IRC nécessitant une intubation trachéale pour ventilation mécanique étaient inclus. Le dosage des valeurs de carnitine était réalisé à l entrée du patient en réanimation. Etaient aussi évalués: le statut nutritionnel, le statut antioxydant total. La morbidité était appréciée par la survenue d une pneumonie acquise sous ventilation mécanique, la durée de ventilation, la durée de séjour en réanimation. Tous les patients bénéficiaient d une nutrition artificielle précoce. Les tests de Mann et Witney, de Spearman et du 2 ont été utilisés pour l analyse statistique. Résultats: 29 patients sont inclus. L âge est de 69 +- 10.8 [73] ans, l albuminémie de 26.7 +- 5.5 [26.2] g/l, la préalbuminémie de 0.12 +- 0.04 [0.12] g/l. La carnitine totale est de 69.9 +- 27.3 [64] mol/l, la carnitine libre de 42.6 +- 20 [36.8] mol/l, la carnitine estérifiée de 27.3 +- 9.7 [24.4] mol/l, et le rapport carnitine estérifiée sur libre de 0.70 +- 0.26 [0.63]. Il y a une corrélation positive entre la carnitine totale et estérifiée et la sélénémie (p<0,05). L incidence des PNAVM est de 27%, la mortalité hospitalière est de 46,6%. Les taux de carnitine mesurés n ont pas de lien statistique avec la DVI, la DSR et la mortalité en réanimation. Conclusion: 90% des patients IRC inclus dans notre travail présentent un déficit en carnitine. Les valeurs initiale de carnitine sont corrélées à la sélénémie Nous ne retrouvons pas de lien satistiquement significatif a été mis en évidence entre les valeurs initiale de carnitine, l état nutritionnel le SAO et la morbi-mortalité.LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Use of sodium-chloride difference and corrected anion gap as surrogates of Stewart variables in critically ill patients.

INTRODUCTION: To investigate whether the difference between sodium and chloride ([Na(+)] - [Cl(-)]) and anion gap corrected for albumin and lactate (AG(corr)) could be used as apparent strong ion difference (SID(app)) and strong ion gap (SIG) surrogates (respectively) in critically ill patients. METHODS: A total of 341 patients were prospectively observed; 161 were allocated to the modeling group, and 180 to the validation group. Simple regression analysis was used to construct a mathematical model between SID(app) and [Na(+)] - [Cl(-)] and between SIG and AG(corr) in the modeling group. Area under the receiver operating characteristic (ROC) curve was also measured. The mathematical models were tested in the validation group. RESULTS: in the modeling group, SID(app) and SIG were well predicted by [Na(+)] - [Cl(-)] and AG(corr) (R(2) = 0.973 and 0.96, respectively). Accuracy values of [Na(+)] - [Cl(-)] for the identification of SID(app) acidosis (47.5 mEq/L) were 0.992 (95% confidence interval [CI], 0.963-1) and 0.998 (95%CI, 0.972-1), respectively. The accuracy of AG(corr) in revealing SIG acidosis (>8 mEq/L) was 0.974 (95%CI: 0.936-0.993). These results were validated by showing excellent correlations and good agreements between predicted and measured SID(app) and between predicted and measured SIG in the validation group (R(2) = 0.977; bias = 0±1.5 mEq/L and R(2) = 0.96; bias = -0.2±1.8 mEq/L, respectively). CONCLUSIONS: SID(app) and SIG can be substituted by [Na(+)] - [Cl(-)] and by AG(corr) respectively in the diagnosis and management of acid-base disorders in critically ill patients

Determinants of noninvasive ventilation success or failure in morbidly obese patients in acute respiratory failure.

PurposeAcute respiratory failure (ARF) is a common life-threatening complication in morbidly obese patients with obesity hypoventilation syndrome (OHS). We aimed to identify the determinants of noninvasive ventilation (NIV) success or failure for this indication.MethodsWe prospectively included 76 consecutive patients with BMI>40 kg/m2 diagnosed with OHS and treated by NIV for ARF in a 15-bed ICU of a tertiary hospital.ResultsNIV failed to reverse ARF in only 13 patients. Factors associated with NIV failure included pneumonia (n = 12/13, 92% vs n = 9/63, 14%; pConclusionsMultiple organ failure and pneumonia were the main factors associated with NIV failure and death in morbidly obese patients in hypoxemic ARF. On the opposite, NIV was constantly successful and could be safely pushed further in case of severe hypercapnic acute respiratory decompensation of OHS

Subgroups analysis of acid-base variables, agreements and intraclass correlation coefficients between observed and predicted values of SID_app and of SIG, and kappa coefficients between SID_app and its surrogate and between SIG and its surrogate in the cross-validation group.

<p>SID_app, apparent strong ion difference; SIG, strong ion gap; AG_corr, anion gap corrected for albumin and lactate; ICC, intraclass correlation coefficient; CI, confidence interval. Metabolic acidosis = SBE<−2 mEq/L, reference range = −2 mEq/L≤SBE≤+2 mEq/L, and metabolic alkalosis = SBE>+2 mEq/L. Agreement is expressed as bias, (95% limits of agreement). All others data are expressed as median with range (minimum, maximum).</p

Subgroups analysis in the septic shock patients of the cross-validation group according to the presence of acute kidney injury and of acute respiratory failure.

<p>AKI, acute kidney injury; ARF, acute respiratory failure, SID_app, apparent strong ion difference; SIG, strong ion gap; AG_corr, anion gap corrected for albumin and lactate; ICC, intraclass correlation coefficient; CI, confidence interval. Agreement is expressed as bias, (95% limits of agreement).</p

Correlation and agreement between observed and predicted strong ion gap (SIG) in the cross-validation group.

<p>Panel A shows the agreement between observed and predicted SIG (bias = −0.2, limits of agreement 95% = −2.1 to 1.6 mEq/L). Panel B shows the correlation between observed and predicted SIG (R2 = 0.96, P<0.0001).</p

Sensitivity, specificity, likelihood ratios, and accuracy of apparent strong ion difference (SID_app) surrogate in the presence of Hyponatremia (Na⁺<135 mEq/L) (n = 57).

<p>LHR⁺, positive likelihood ratio; LHR⁻, negative likelihood ratio; CI, confidence interval.</p

Arterial blood gases at the time of noninvasive ventilation (NIV) initiation (H0), after 2 hrs of NIV (H2), and at the time of NIV failure (failure) in patients of the early NIV failure group (n = 13, left column).

<p>By comparison, arterial blood gases evolution during the first 48(n = 30, central column) and in patients with a delayed response to NIV (n = 33, right column).</p

Flow chart showing patients' outcome according to early (within the first 48 hrs) or late (after the 48^th hr) NIV success or failure.

<p>NIV  =  noninvasive ventilation; ARF  =  acute respiratory failure; OHS  =  obesity hypoventilation syndrome; DNI  =  do-not-intubate.</p

Patients characteristics at admission.

<p>Abbreviations: BMI, body mass index; NIV, non-invasive ventilation; ARF, acute respiratory failure; MRC, Medical Research Council dyspnea score; OSAS, obstructive sleep apnea syndrome; DNI status, do-not-intubate status; SAPS 2, simplified acute physiologic score 2; SOFA score, sequential organ failure assessment score; SABP, systolic arterial blood pressure.</p