Invasive pulmonary aspergillosis in patients with decompensated cirrhosis: case series

BACKGROUND: Opportunistic invasive fungal infections are increasingly frequent in intensive care patients. Their clinical spectrum goes beyond the patients with malignancies, and for example invasive pulmonary aspergillosis has recently been described in critically ill patients without such condition. Liver failure has been suspected to be a risk factor for aspergillosis. CASE PRESENTATION: We describe three cases of adult respiratory distress syndrome with sepsis, shock and multiple organ failure in patients with severe liver failure among whom two had positive Aspergillus antigenemia and one had a positive Aspergillus serology. In all cases bronchoalveolar lavage fluid was positive for Aspergillus fumigatus. Outcome was fatal in all cases despite treatment with voriconazole and agressive symptomatic treatment. CONCLUSION: Invasive aspergillosis should be among rapidly raised hypothesis in cirrhotic patients developing acute respiratory symptoms and alveolar opacities

Prognosis of patients with primary malignant brain tumors admitted to the intensive care unit: a two-decade experience

International audienceThe purpose of this study is to describe the reasons for ICU admission and to evaluate the outcome and prognostic factors of patients with primary malignant brain tumors (PMBT) admitted to the intensive care unit (ICU). This is a retrospective observational cohort study of 196 PMBT patients admitted to two ICUs over a 19-year period. Acute respiratory failure was the main reason for ICU admission (45%) followed by seizures (25%) and non-epileptic coma (14%). Seizures were more common in patients with glial lesions (84 vs. 67%), whereas patients with primary brain lymphoma were more frequently admitted for shock (42 vs. 18%). Overall ICU and 90-day mortality rates were 23 and 50%, respectively. Admission for seizures was independently associated with lower ICU mortality [odds ratio (OR) 0.06], whereas the need for mechanical ventilation (OR 6.85), cancer progression (OR 7.84), respiratory rate (OR 1.11) and Glasgow coma scale (OR 0.85) were associated with higher ICU mortality. Among the 95 patients who received invasive mechanical ventilation, ICU mortality was 37% (n = 35). For these patients, admission for seizures was associated with lower ICU mortality (OR 0.050) whereas cancer progression (OR 7.49) and respiratory rate (OR 1.08) were associated with higher ICU mortality. The prognosis of PMBT patients admitted to the ICU appears relatively favorable compared to that of hematologic malignancies or solid tumors, especially when the patient is admitted for seizures. The presence of a PMBT, therefore, does not appear to be sufficient for refusal of ICU admission. Predictive factors of mortality may help clinicians make optimal triage decisions

Patterns of diaphragm function in critically ill patients receiving prolonged mechanical ventilation: a prospective longitudinal study

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Aspergillus flavus brain abscesses associated with hepatic amebiasis in a non-neutropenic man in Senegal

A non-neutropenic man living in Senegal was repatriated to France for liver amebic abscesses associated with brain abscesses presumed to be of amebic origin. Surprisingly, the post-mortem examinations of brain abscesses showed Aspergillus flavus. The route of infection by A. flavus in this particular context is discussed

Diaphragm Dysfunction on Admission to the Intensive Care Unit. Prevalence, Risk Factors, and Prognostic Impact—A Prospective Study

International audienceRationale: Diaphragmatic insults occurring during intensive care unit (ICU) stays have become the focus of intense research. However, diaphragmatic abnormalities at the initial phase of critical illness remain poorly documented in humans. Objectives: To determine the incidence, risk factors, and prognostic impact of diaphragmatic impairment on ICU admission. Methods: Prospective, 6-month, observational cohort study in two ICUs. Mechanically ventilated patients were studied within 24 hours after intubation (Day 1) and 48 hours later (Day 3). Seventeen anesthetized intubated control anesthesia patients were also studied. The diaphragm was assessed by twitch tracheal pressure in response to bilateral anterior magnetic phrenic nerve stimulation (Ptr,stim). Measurements and Main Results: Eighty-five consecutive patients aged 62 (54-75) (median [interquartile range]) were evaluated (medical admission, 79%; Simplified Acute Physiology Score II, 54 [44-68]). On Day 1, Ptr, stim was 8.2 (5.9-12.3) cm H2O and 64% of patients had Ptr, stim less than 11 cm H2O. Independent predictors of low Ptr, stim were sepsis (linear regression coefficient, -3.74; standard error, 1.16; P = 0.002) and Simplified Acute Physiology Score II (linear regression coefficient, -0.07; standard error, 1.69; P = 0.03). Compared with nonsurvivors, ICU survivors had higher Ptr, stim (9.7 [6.3-13.8] vs. 7.3 [5.5-9.7] cm H2O; P = 0.004). This was also true for hospital survivors versus nonsurvivors (9.7 [6.3-13.5] vs. 7.8 [5.5-10.1] cm H2O; P = 0.004). Day 1 and Day 3 Ptr, stim were similar. Conclusions: A reduced capacity of the diaphragm to produce inspiratory pressure (diaphragm dysfunction) is frequent on ICU admission. It is associated with sepsis and disease severity, suggesting that it may represent another form of organ failure. It is associated with a poor prognosis

Control of tracheal cuff pressure: a pilot study using a pneumatic device

Abstract Objective: To evaluate the efficacy of a simple mechanical device to maintain constant endotracheal cuff pressure (Pcuff) during mechanical ventilation (large encased inflatable cuff connected to the endotracheal cuff and receiving constant pressure from a heavy mass attached to an articulated arm). Design and setting: Single-center, prospective, randomized, crossover, pilot study in a medical intensive care unit. Patients and participants: Nine consecutive mechanically ventilated patients (age 62 ± 20 years, SAPS II score 39 ± 15). Interventions: Control day: Pcuff monitored and adjusted with a manometer (Hi-Lo™, Tyco Healthcare) according to current recommendations (twice a day and after each intervention on the tracheal tube); initial target Pcuff 22-28 cmH 2 0. Prototype day: test device connected to the endotracheal cuff; same initial target. Continuous Pcuff recording during both days. Control and prototype days in random order. Results: Pcuff values over 50 cmH 2 0 were recorded in six patients during the control day (178 ± 159 min), never during the prototype day. During the control day, Pcuff was between 30 and 50 cmH 2 0 for 29 ± 25% of the time, vs 0.3 ± 0.3% during the prototype day (p < 0.01). Pcuff was between 15 and 30 cmH 2 0 for 56 ± 36% of the time during the control day, vs 95 ± 14% during the prototype day (p < 0.01). During the control day, Pcuff was below 15 cmH 2 0 for 15 ± 17% of the time, vs 4.7 ± 15% during the prototype day (p < 0.05). Conclusions: The tested device successfully controlled Pcuff with minimal human resource consumption. Prospective studies are required to assess its clinical impact

Safety of performing fiberoptic bronchoscopy in critically ill hypoxemic patients with acute respiratory failure.: Bronchoscopy in Hypoxemic Patients

International audienceBACKGROUND: The safety of fiberoptic bronchoscopy (FOB) in nonintubated critically ill patients with acute respiratory failure has not been extensively evaluated. We aimed to measure the incidence of intubation and the need to increase ventilatory support following FOB and to identify predictive factors for this event. METHODS: A prospective multicenter observational study was carried out in eight French adult intensive care units. The study included 169 FOB performed in patients with a PaO(2)/FiO(2) ratio ≤ 300. The main end-point was intubation rate. The secondary end-point was rate of increased ventilatory support defined as an increase in oxygen requirement >50 %, the need to start noninvasive positive pressure ventilation (NI-PPV) or increase NI-PPV support. RESULTS: Within 24 h, an increase in ventilatory support was required following 59 bronchoscopies (35 %), of which 25 (15 %) led to endotracheal intubation. The existence of chronic obstructive pulmonary disease (COPD; OR 5.2, 95 % CI 1.6-17.8; p = 0.007) or immunosuppression (OR 5.4, 95 % CI 1.7-17.2; p = 0.004] were significantly associated with the need for intubation in the multivariable analysis. None of the baseline physiological parameters including the PaO(2)/FiO(2) ratio was associated with intubation. CONCLUSIONS: Bronchoscopy is often followed by an increase in ventilatory support in hypoxemic critically ill patients, but less frequently by the need for intubation. COPD and immunosuppression are associated with the need for invasive ventilation in the 24 h following bronchoscopy