Prognostic value of right ventricular dilatation on computed tomography pulmonary angiogram for predicting adverse clinical events in severe COVID-19 pneumonia

BackgroundRight ventricle dilatation (RVD) is a common complication of non-intubated COVID-19 pneumonia caused by pro-thrombotic pneumonitis, intra-pulmonary shunting, and pulmonary vascular dysfunction. In several pulmonary diseases, RVD is routinely measured on computed tomography pulmonary angiogram (CTPA) by the right ventricle-to-left ventricle (LV) diameter ratio > 1 for predicting adverse events.ObjectiveThe aim of the study was to evaluate the association between RVD and the occurrence of adverse events in a cohort of critically ill non-intubated COVID-19 patients.MethodsBetween February 2020 and February 2022, non-intubated patients admitted to the Amiens University Hospital intensive care unit for COVID-19 pneumonia with CTPA performed within 48 h of admission were included. RVD was defined by an RV/LV diameter ratio greater than one measured on CTPA. The primary outcome was the occurrence of an adverse event (renal replacement therapy, extracorporeal membrane oxygenation, 30-day mortality after ICU admission).ResultsAmong 181 patients, 62% (n = 112/181) presented RVD. The RV/LV ratio was 1.10 [1.05–1.18] in the RVD group and 0.88 [0.84–0.96] in the non-RVD group (p = 0.001). Adverse clinical events were 30% and identical in the two groups (p = 0.73). In Receiving operative curves (ROC) analysis, the RV/LV ratio measurement failed to identify patients with adverse events. On multivariable Cox analysis, RVD was not associated with adverse events to the contrary to chest tomography severity score > 10 (hazards ratio = 1.70, 95% CI [1.03–2.94]; p = 0.04) and cardiovascular component (> 2) of the SOFA score (HR = 2.93, 95% CI [1.44–5.95], p = 0.003).ConclusionRight ventricle (RV) dilatation assessed by RV/LV ratio was a common CTPA finding in non-intubated critical patients with COVID-19 pneumonia and was not associated with the occurrence of clinical adverse events

Antifungal treatment (except haematology). What do the data really show?

International audienceYeast infections are becoming more common in intensive care. Moreover, they are clearly associated with an increase in morbidity and mortality. Candida albicans is the most common species in invasive candidiasis in ICU and in Europe. Many risk factors are identified and a number of predictive scores for candidiasis have been developed but they are not performing well. The delayed start of treatment is an independent factor of mortality. Four classes of antifungals are available: polyenes, triazoles, echinocandins and flucytosine. Their cellular action mechanisms and activity spectra are different and must be known. In patients with severe candidemia, firstline therapy should include an echinocandin for 14 days after the first negative blood culture. An extension assessment should always be performed in case of candidemia (occular examination and trans-oesophageal echocardiography). During intra-abdominal infections, antifungal treatment with echinocandin should probably be introduced if at least 3 predictive criteria are present (haemodynamic failure, female gender, sus-mesocolic surgery, antibiotic therapy for more than 48 hours) or in case of direct positive examination to yeast. All recommendations on preventive antifungal therapy are recommendations of very low level of evidence and do not allow to define a therapeutic strategy. Therapeutic de-escalation should be as early as possible and seem to have no impact on morbidity and mortality

Blood pressure target in anaesthesia and intensive care

International audienceBlood pressure is subject to constant autoregulation in order to maintain values that are ``adapted `` to the body's needs. This depends on different mechanisms acting at different levels and in different time frames. The blood pressure targets are varied due to the patient's condition, the type of surgery considered in anaesthesia and the aetiology of shock in intensive care. In non-cardiac surgery, an ``absolute `` threshold of MAP lower than 60-70 mmHg, SAP lower than 90 mmHg and higher than 160 mmHg would be associated with postoperative complications. The individualisation of blood pressure objectives by targeting a preoperative reference value seems to be a relevant practice from a pathophysiological point of view but needs to be further studied. In cardiac surgery, it does not seem appropriate to maintain a high MAP target during extracorporeal circulation, while not exceeding a SAP of 140 mmHg. During cardiogenic shock, evidences allow us to position ourselves on an early use of catecholamines with a target MAP > 70 mmHg. During septic shock, it is advisable to target a MAP > 65 mmHg according to the latest recommendations. During haemorrhagic shock, fluid resuscitation should be limited with early use of vasopressors if necessary in case of threatening arterial hypotension (SAP < 80 mmHg and/or MAP < 60 mmHg). In cases of severe traumatic brain injury, a cerebral perfusion pressure higher than 60-70 mmHg should be maintained

Retrograde cerebral venous air embolism following difficult intubation

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A norepinephrine weaning strategy using dynamic arterial elastance is associated with reduction of acute kidney injury in patients with vasoplegia after cardiac surgery: A post-hoc analysis of the randomized SNEAD study.

International audienceStudy objective: To evaluate the impact of a dynamic arterial elastance guided norepinephrine weaning strategy on the occurrence of acute kidney injury (AKI) in patients with vasoplegia after cardiac surgery.Design: A post-hoc analysis of a monocentric randomized controlled trial.Setting: A tertiary care hospital in France.Participants: Vasoplegic cardiac surgical patients treated with norepinephrine.Intervention: Patients were randomized to an algorithm-based norepinephrine weaning intervention (dynamic arterial elastance) group or a control group.Measurements: The primary endpoint was the number of patients with AKI defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The secondary endpoint were major adverse cardiac post-operative events (new onset of atrial fibrillation or flutter, low cardiac output syndrome, and in-hospital death). End points were evaluated during the first seven post-operative days.Results: 118 patients were analyzed. In the overall study population, the mean age was 70 (62-76) years, 65% were male and the median EuroSCORE was 7 (5-10). Overall, 46 (39%) patients developed AKI (30 KDIGO 1, 8 KDIGO 2, 8 KDIGO 3), and 6 patients required renal replacement therapy. The incidence of AKI was significantly lower in the intervention group than in the control group (16 patients (27%) vs 30 patients (51%), p = 0.12). Higher dose and longer duration of norepinephrine were associated with AKI severity.Conclusion: Decreasing norepinephrine exposure by using a dynamic arterial elastance guided norepinephrine weaning strategy was associated with a reduced incidence of acute kidney injury in patients with vasoplegia after cardiac surgery. Further prospective multicentric studies are needed to confirm these results

Fluid Challenge: From bench to bedside

International audienceAdverse effects of fluid loading ore not only due to the specific toxicity of infused fluid but also to the amount of the infused fluid. To avoid these adverse effects, the concept of ``Fluid Challenge'' (FC) has been developed. FC tests the ability of the cardiovascular system to increase stroke volume with minimal fluid loading. Hence, FC should not be used for overt hypovolaemia especially at the early phase of shock. Response to fluid challenge should be evaluated with stroke volume measurement. An increase of stroke volume by 10-15% is considered as significant. The most reliable tools to evaluate stroke volume variations are pulmonary thermodilution, transpulmonory thermodilution and Doppler echocardiography. To date, there is no consensus statement on the modalities of FC. Based on published studies, we suggest the use of crystalloids of a perfusion rote of 200-250 mL in 5-10 min. We also suggest evaluating the responsiveness at 20-30 min. Finally, FC should be stopped if signs of fluid overload appear (pulmonary oedema, venous congestion)

Tracheal trauma after difficult airway management in morbidly obese patients with COVID-19

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Hyperoxia during cardiopulmonary bypass does not increase respiratory or neurological complications: a post hoc analysis of the CARDIOX study

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The ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content are not associated with overall anaerobic metabolism in postoperative cardiac surgery patients.

BACKGROUND:The aim of the present study was to evaluate the ability of the ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content to predict an increase in oxygen consumption (VO2) upon fluid challenge (FC). METHODS AND RESULTS:110 patients admitted to cardiothoracic ICU and in whom the physician had decided to perform an FC (with 500 ml of Ringer's lactate solution) were included. The arterial pressure, cardiac index (Ci), and arterial and venous blood gas levels were measured before and after FC. VO2 and CO2-O2 derived variables were calculated. VO2 responders were defined as patients showing more than a 15% increase in VO2. Of the 92 FC responders, 43 (46%) were VO2 responders. At baseline, pCO2 gap, C(a-v)O2 were lower in VO2 responders than in VO2 non-responders, and central venous oxygen saturation (ScvO2) was higher in VO2 responders. FC was associated with an increase in MAP, SV, and CI in both groups. With regard to ScvO2, FC was associated with an increase in VO2 non-responders and a decrease in VO2 responders. FC was associated with a decrease in pvCO2 and pCO2 gap in VO2 non-responders only. The pCO2 gap/C(a-v)O2 ratio and C(a-v)CO2 content /C(a-v)O2 content ratio did not change with FC. The CO2 gap content/C(a-v)O2 content ratio and the C(a-v)CO2 content /C(a-v)O2 content ratio did not predict fluid-induced VO2 changes (area under the curve (AUC) [95% confidence interval (CI)] = 0.52 [0.39‒0.64] and 0.53 [0.4-0.65], respectively; p = 0.757 and 0.71, respectively). ScvO2 predicted an increase of more than 15% in the VO2 (AUC [95%CI] = 0.67 [0.55‒0.78]; p<0.0001). CONCLUSIONS:Our results showed that the ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content were not predictive of VO2 changes following fluid challenge in postoperative cardiac surgery patients

Tricuspid Longitudinal Annular Displacement for the Assessment of Right Ventricular Systolic Dysfunction during Prone Positioning in Patients with COVID-19

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