Influence de la Pression Artérielle Moyenne per CEC dans l'apparition d'hypoxémie post-opératoire chez les patients opérés d'une dissection aortique de type A en urgence

L’hypoxémie post opératoire (HPO) est une complication majeure des dissections aortiques de type A (DAoA), à l’origine d’une importante morbi-mortalité, d’un allongement de la durée d’hospitalisation et de ventilation mécanique. Il n’existe actuellement pas de données concernant la relation entre HPO et hypotension per CEC (Circulation Extra Corporelle). Il est intéressant d’évaluer son impact afin de pouvoir améliorer la prise en charge péri-opératoire de ces patients. Nous avons étudié le lien entre hypotension per CEC et hypoxémie post opératoire dans la chirurgie de dissection aortique de type A. Matériel & Méthodes : nous avons réalisé une étude rétrospective monocentrique sur 3 ans dans l’unité de réanimation cardio-vasculaire de l’hôpital de la Timone à Marseille (URCV). Nous avons inclus toutes les dissections aortiques de type A prises en charge dans notre centre. Nous avons exclu les facteurs connus pour favoriser l’hypoxémie post opératoire : choc septique, choc cardiogénique, infarctus du myocarde, assistance extra-corporelle respiratoire ou circulatoire. Nous avons d’abord analysé le risque d’HPO en fonction de la pression artérielle moyenne (PAM) et de la durée d’hypotension per CEC. Nous en avons déduit un seuil de PAM combiné à un seuil de durée d’hypotension augmentant le risque d’HPO. Ensuite, une analyse par matching de score de propension stratifiée sur le risque d’hypotension per CEC analysait le lien entre HPO et hypotension per CEC de manière multivariée. Enfin une analyse par régression logistique multiple recherchait les facteurs de risques indépendants d’HPO. Résultats : nous avons inclus 145 patients sur les 189 patients ayant présenté une DAoA entre 2018 et 2020. L’incidence d’HPO était de 50.3%. La PAM per CEC apparaissait plus basse (60.3 [21] vs 62.3 [21] mmHg, p < 0.001) et le débit de CEC plus élevé (4.3 [1.1] vs 4.2 [1.1] L/min, p < 0.001) dans le groupe HPO. L’hypoxémie survenait dans les 48 premières heures post opératoires. Sur la population matchée par score de propension, l'HPO survient chez 58 % des patients ayant présenté une PAM per CEC < 50 mmHg durant plus de 15 minutes contre 34 % sans hypotension per CEC (p=0.02). Le risque relatif d’HPO augmente de 41 % dans le groupe PAM per CEC < 50 mmHg durant plus de 15 minutes (OR 2.7 – IC 95% [1.2 – 6], p = 0.02). Nous avons identifié 3 facteurs de risques indépendants supplémentaires d’HPO : l’hypoxémie pré-opératoire (OR 18.3 – IC 95% [3.23-346.4], p = 0.007), l’allongement de la durée de CEC (OR 1.01 – IC 95% [1.0-1.02], p = 0.03) et le surpoids (OR 2.38 – IC 95% [1.02 – 5.73], p = 0.04). Conclusion : l’hypotension per CEC (PAM < 50 mmHg durant plus de 15 minutes), le surpoids, l’augmentation de la durée de CEC et l’hypoxémie pré-opératoire apparaissent comme des facteurs de risque indépendants d’hypoxémie post opératoire chez les patients opérés en urgence d’une dissection aortique de type A

Incidence, Outcomes and Risk Factors of Recurrent Ventilator Associated Pneumonia in COVID-19 Patients: A Retrospective Multicenter Study

Background: High incidence of ventilator associated pneumonia (VAP) has been reported in critically ill patients with COVID-19. Among these patients, we aimed to assess the incidence, outcomes and risk factors of VAP recurrences. Methods: We conducted an observational retrospective study in three French intensive care units (ICUs). Patients admitted for a documented COVID-19 from March 2020 to May 2021 and requiring mechanical ventilation (MV) for ≥48 h were included. The study main outcome was the incidence of VAP recurrences. Secondary outcomes were the duration of MV, ICU and hospital length of stay and mortality according to VAP and recurrences. We also assessed the factors associated with VAP recurrences. Results: During the study period, 398 patients met the inclusion criteria. A total of 236 (59%) of them had at least one VAP episode during their ICU stay and 109 (46%) of these patients developed at least one recurrence. The incidence of VAP recurrence considering death and extubation as competing events was 29.6% (IC = [0.250–0.343]). Seventy-eight percent of recurrences were due to the same bacteria (relapses). Patients with a VAP recurrence had a longer duration of MV as compared with one VAP and no VAP patients (41 (25–56) vs. 16 (8–30) and 10 (5–18) days; p p p = 0.021)). In a multivariate analysis including bacterial co-infection at admission, the use of immunosuppressive therapies and the bacteria responsible for the first VAP episode, the duration of MV was the only factor independently associated with VAP recurrence. Conclusion: In COVID-19 associated respiratory failure, recurrences affected 46% of patients with a first episode of VAP. VAP recurrences were mainly relapses and were associated with a prolonged duration of MV and ICU length of stay but not with a higher mortality. MV duration was the only factor associated with recurrences

Factors Associated with 90-Day Mortality in Invasively Ventilated Patients with COVID-19 in Marseille, France

International audienceOBJECTIVES: To describe clinical characteristics and management of intensive care units (ICU) patients with laboratory-confirmed COVID-19 and to determine 90-day mortality after ICU admission and associated risk factors. METHODS: This observational retrospective study was conducted in six intensive care units (ICUs) in three university hospitals in Marseille, France. Between 10 March and 10 May 2020, all adult patients admitted in ICU with laboratory-confirmed SARS-CoV-2 and respiratory failure were eligible for inclusion. The statistical analysis was focused on the mechanically ventilated patients. The primary outcome was the 90-day mortality after ICU admission. RESULTS: Included in the study were 172 patients with COVID-19 related respiratory failure, 117 of whom (67%) received invasive mechanical ventilation. 90-day mortality of the invasively ventilated patients was 27.4%. Median duration of ventilation and median length of stay in ICU for these patients were 20 (9-33) days and 29 (17-46) days. Mortality increased with the severity of ARDS at ICU admission. After multivariable analysis was carried out, risk factors associated with 90-day mortality were age, elevated Charlson comorbidity index, chronic statins intake and occurrence of an arterial thrombosis. CONCLUSION: In this cohort, age and number of comorbidities were the main predictors of mortality in invasively ventilated patients. The only modifiable factor associated with mortality in multivariate analysis was arterial thrombosis