Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the 'optimal' flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of 'high-ECMO flow'. A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as 'high-flow' or 'low-flow', respectively, when median ECMO flow was ≥3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40-59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as 'high-flow'. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26-58) vs. 56 (42-74), P < 0.001], higher lactate [3.6 (2.2-5.8) mmol/L vs. 5.2 (3-9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41-375) U/L vs. 309 (85-939) U/L, P < 0.001], among others. The 'low-flow' group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5-7.5) vs. 6 (3-12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with 'high-flow' were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1-7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0-1.2). In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows

What’s new in myocarditis?

International audienceMyocarditis is an illness characterized by myocardial infiltration with inflammatory cells and non-ischemic myocyte necrosis. Typical histological finding is lymphocytic infiltration, but other forms involving eosinophilic or giant-cell inflammation exist. Coronary vasculitis is another pathogenic mechanism in some instances. The leading causes are infectious diseases, most commonly viral; immune-mediated injury (triggered by viral infection, allogenic agents such as drugs or associated with autoimmune disease); and toxins.[...

Heparin-induced thrombocytopenia in COVID-19 patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation: two case reports

International audienceVeno-venous (VV) extracorporeal membrane oxygenation (ECMO) is increasingly used in Coronavirus disease-19 (COVID-19) patients with the most severe forms of acute respiratory distress syndrome (ARDS). Its use is associated with a significant hemostatic challenge, especially in COVID- 19 patients who have been demonstrated to otherwise present a COVID-19-associated coagulopathy. The systematic use of unfractionated heparin therapy to prevent circuit thrombosis is warranted during ECMO support. The clinical presentation and management of heparin-induced thrombocytopenia, which is a rare but life-threatening complication of heparin therapy, has not been described in those patients yet. We report herein two cases of laboratory-confirmed HIT in COVID-19 patients with severe ARDS admitted to our intensive care unit for VV-ECMO support and the successful use of argatroban as an alternative therapy. We also provide a brief literature review of best evidence for managing such patients. The diagnosis and management of HIT is particularly challenging in COVID-19 patients receiving ECMO support. An increased awareness is warranted in those patients who already present a procoagulant state leading to higher rates of thrombotic events which can confuse the issues. Argatroban seems to be an appropriate and safe therapeutic option in COVID-19 patients with HIT while on VV-ECMO

Severe pulmonary embolism in COVID-19 patients: a call for increased awareness

International audienceNo abstract availabl

Intérêt de l’échocardiographie trans-œsophagienne tridimensionnelle pour évaluer le débit cardiaque chez les patients admis en réanimation : étude pilote

International audienceBackgroundThree-dimensional transoesophageal echocardiography (3D-TOE) is a new noninvasive tool for quantitative assessment of left ventricular (LV) volumes and ejection fraction.AimThe objective of this pilot study was to evaluate the feasibility and accuracy of 3D-TOE for the estimation of cardiac output (CO), using transpulmonary thermodilution with the Pulse index Contour Continuous Cardiac Output (PiCCO) system as the reference method, in intensive care unit (ICU) patients.MethodsFifteen ICU patients on mechanical ventilation prospectively underwent PiCCO catheter implantation and 3D-TOE. 3D-TOE LV end-diastolic and end-systolic volumes were determined using semi-automated software. CO was calculated as the product of LV stroke volume (end-diastolic volume − end-systolic volume) multiplied by heart rate. CO was also determined invasively by transpulmonary thermodilution as the reference method.ResultsAmong 30 haemodynamic evaluations, 29 (97%) LV 3D-TOE datasets were suitable for CO calculation. The mean 3D-TOE image acquisition and post-processing times were 46 and 155 seconds, respectively. There was a correlation (r = 0.78; P < 0.0001) between PiCCO and 3D-TOE CO. Compared with PiCCO, the 3D-TOE CO mean bias was 0.38 L/min, with limits of agreement of −1.97 to 2.74 L/min.ConclusionsNoninvasive estimation of CO by 3D-TOE is feasible in ICU patients. This new semi-automated modality is an additional promising tool for noninvasive haemodynamic assessment of ICU patients. However, the wide limits of agreement with thermodilution observed in this pilot study require further investigation in larger cohorts of patients.ContexteL’échocardiographie trans-œsophagienne tridimensionelle (ETO-3D) est une nouvelle modalité non invasive d’évaluation des volumes et de la fraction d’éjection du ventricule gauche (VG).ObjectifÉvaluer la faisabilité et la performance de l’ETO-3D comparativement à la thermodilution transpulmonaire par méthode PiCCO pour la mesure du débit cardiaque (DC).MéthodesDans cette étude pilote, 15 patients sous ventilation mécanique admis en réanimation et bénéficiant d’un monitorage hémodynamique invasif par le système PiCCO ont été prospectivement évalués par ETO-3D. Les volumes télé-diastolique et télé-systolique du VG ont été mesurés en utilisant un logiciel semi-automatique spécifique. Le DC a ensuite été calculé en multipliant le volume d’éjection systolique du VG (volume télé-diastolique − volume télé-systolique) par la fréquence cardiaque. Le DC a également été mesuré de façon invasive par thermodilution transpulmonaire.RésultatsParmi les 30 évaluations hémodynamiques effectuées, 29 (97 %) acquisitions ETO-3D étaient exploitables. Les temps moyens nécessaires pour l’acquisition et l’analyse des données ETO-3D étaient respectivement de 46 et 155 secondes. Les mesures de DC effectuées par ETO-3D et par méthode invasive étaient corrélées (r = 0,78 ; p < 0,0001). Le biais moyen entre les 2 méthodes de mesure était de 0,38 L/min, les limites d’agrément étaient de −1,97 à 2,74 L/min.ConclusionsL’évaluation non invasive du DC par ETO-3D est faisable. Cette nouvelle modalité ultrasonore est un outil prometteur pour l’évaluation hémodynamique des patients admis en réanimation. Les limites d’agrément relativement larges observées dans cette étude pilote comparativement à la theromdilution nécessitent toutefois d’être évaluer sur de plus larges populations de patients

Antibiotic stewardship in the ICU: time to shift into overdrive

Abstract Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs

Early Reversal of Right Ventricular Dysfunction after Venovenous Extracorporeal Membrane Oxygenation in Patients with COVID-19 Pneumonia

International audienceNo abstract availabl

Co-infection with influenza-associated acute respiratory distress syndrome requiring extracorporeal membrane oxygenation

International audienceCo-infection frequency and impact among influenza-associated acute respiratory distress syndrome (ARDS) patients requiring extracorporeal membrane oxygenation (ECMO) are not known. This retrospective, observational analysis concerned data prospectively collected from patients admitted to our medical intensive care unit (ICU) who received ECMO support for influenza-associated ARDS between 2009 and 2016. Co-infection was defined as occurring within 48 hours following ICU admission. Among the 77 ARDS patients requiring ECMO support, 39 (51%) developed co-infections, with Staphylococcus aureus (18 (46%) of the co-infected) being the most prevalent pathogen. Panton–Valentin leukocidin (PVL)-producing S. aureus was isolated from ten patients (56% of S. aureus co-infections and 26% of all co-infections). Except for body mass index, initial disease severity and antibiotic treatment prior to admission, patients with co-infection were comparable to those without. Co-infection was associated with higher in-ICU mortality (62% vs. 29% without; p=0.006), and, on day 60, (median [interquartile range]) fewer ECMO-free days (0 [0–19] vs. 23 [0–46]; p=0.004) and fewer mechanical ventilation-free days (0 [0–0] vs. 6 [0–35]; p=0.003). Multivariable analyses retained age >49 years, pre-ECMO Simplified Acute Physiology Score II >70 and co-infection as independent predictors of hospital mortality. In conclusion, co-infection is frequent in ECMO-treated patients with influenza-associated ARDS, affecting ~50% of them, and is independently associated with poor outcome. S. aureus was the most frequently identified pathogen, with a high rate of PVL-positive S. aureus. Whether specific therapy targeting PVL-producing S. aureus should be given remains to be determined

Prone positioning monitored by electrical impedance tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO

International audienceBackground: Prone positioning (PP) during veno-venous ECMO is feasible, but its physiological effects have never been thoroughly evaluated. Our objectives were to describe, through electrical impedance tomography (EIT), the impact of PP on global and regional ventilation, and optimal PEEP level.Methods: A monocentric study conducted on ECMO-supported severe ARDS patients, ventilated in pressure-controlled mode, with 14-cmH2O driving pressure and EIT-based "optimal PEEP". Before, during and after a 16-h PP session, EIT-based distribution and variation of tidal impedance, VTdorsal/VTglobal ratio, end-expiratory lung impedance (EELI) and static compliance were collected. Subgroup analyses were performed in patients who increased their static compliance by ≥ 3 mL/cmH2O after 16 h of PP.Results: For all patients (n = 21), tidal volume and EELI were redistributed from ventral to dorsal regions during PP. EIT-based optimal PEEP was significantly lower in PP than in supine position. Median (IQR) optimal PEEP decreased from 14 (12-16) to 10 (8-14) cmH2O. Thirteen (62%) patients increased their static compliance by ≥ 3 mL/cmH2O after PP on ECMO. This subgroup had higher body mass index, more frequent viral pneumonia, shorter ECMO duration, and lower baseline VTdorsal/VTglobal ratio than patients with compliance ≤ 3 mL/cmH2O (P < 0.01).Conclusion: Although baseline tidal volume distribution on EIT may predict static compliance improvement after PP on ECMO, our results support physiological benefits of PP in all ECMO patients, by modifying lung mechanics and potentially reducing VILI. Further studies, including a randomized-controlled trial, are now warranted to confirm potential PP benefits during ECMO

Outcomes of Patients Denied ECMO During the COVID-19 Pandemic in Greater Paris, France

International audienc