Implémentation d'un protocole de réhabilitation améliorée après transplantation hépatique : faisabilité et analyse des résultats

Médecine. Anesthésie et réanimationIntroduction : la transplantation hépatique est à ce jour le seul traitement curatif des insuffisances hépatiques terminales. Malgré l’amélioration des techniques chirurgicales, elle est encore considérée comme une chirurgie majeure, à haut risque de complications. Aucune recommandation d’experts n’existe quant à un programme de réhabilitation améliorée après transplantation hépatique. Notre étude a pour but de proposer un tel protocole, d’en évaluer la possibilité de mise en place et d’en analyser les résultats. Méthode : nous avons mené une étude rétrospective, descriptive, au sein du service d’anesthésie-réanimation chirurgicale de l’hôpital de Hautepierre au centre hospitalier universitaire de Strasbourg sur une période de 16 mois. Le protocole de réhabilitation améliorée comportait une phase peropératoire centrée sur l’utilisation d’agents pharmacologiques à courte durée d’action et l’épargne transfusionnelle. La phase postopératoire réanimatoire était basée sur le déconditionnement rapide des patients. Le succès d’implémentation du protocole était défini par le respect de 4 critères sur les 6 retenus. Les patients répondant à cet objectif constituaient le groupe RAAC de notre étude. Résultats : sur les 61 patients inclus, le protocole de réhabilitation améliorée a pu être appliqué chez 25 d’entre eux. Dans le groupe RAAC, la durée d’hospitalisation en réanimation et la durée d’hospitalisation totale étaient diminuées de façon significative, respectivement de 3 et de 10 jours. Aucune différence significative n’a été observée entre les deux groupes en termes de survenue de complications postopératoires. La mortalité en réanimation et à J90 était nulle dans le groupe RAAC. Conclusion : la mise en place d’un protocole de réhabilitation accélérée semble améliorer la convalescence des patients en postopératoire d’une transplantation hépatique sans en augmenter la morbi-mortalité

Strengthening and drying rate of a drying emulsion layer

International audienceFrom direct observations and MRI measurements we demonstrate that during the drying of a direct (oil in water) emulsion the whole system essentially concentrates homogeneously, which leads to shrinkage, without air penetration. The structure and mechanical strength (i.e. the elastic modulus) of this concentrated bulk are not significantly different from those of an emulsion directly prepared at this higher concentration. Despite this phenomenon, the drying rate continuously and rapidly decreases as the water content decreases, in contrast with the drying of a simple granular packing. This results from a concentration gradient which develops towards the free surface of the sample where the oil droplets finally coalesce, ultimately forming an oil layer covering the sample through which the water molecules have to diffuse before evaporating. Moreover, as during the process, the liquid is transported towards the free surface where it evaporates, surfactants accumulate and tend to form a thin solid layer below the oil layer, which tends to further reduce the drying rate

Outcomes of Stenotrophomonas maltophilia hospital-acquired pneumonia in intensive care unit: a nationwide retrospective study

International audienceBackground: There is little descriptive data on Stenotrophomonas maltophilia hospital-acquired pneumonia (HAP) in critically ill patients. The optimal modalities of antimicrobial therapy remain to be determined. Our objective was to describe the epidemiology and prognostic factors associated with S. maltophilia pneumonia, focusing on antimicrobial therapy.Methods: This nationwide retrospective study included all patients admitted to 25 French mixed intensive care units between 2012 and 2017 with hospital-acquired S. maltophilia HAP during intensive care unit stay. Primary endpoint was time to in-hospital death. Secondary endpoints included microbiologic effectiveness and antimicrobial therapeutic modalities such as delay to appropriate antimicrobial treatment, mono versus combination therapy, and duration of antimicrobial therapy.Results: Of the 282 patients included, 84% were intubated at S. maltophilia HAP diagnosis for duration of 11 [5-18] days. The Simplified Acute Physiology Score II was 47 [36-63], and the in-hospital mortality was 49.7%. Underlying chronic pulmonary comorbidities were present in 14.1% of cases. Empirical antimicrobial therapy was considered effective on S. maltophilia according to susceptibility patterns in only 30% of cases. Delay to appropriate antimicrobial treatment had, however, no significant impact on the primary endpoint. Survival analysis did not show any benefit from combination antimicrobial therapy (HR = 1.27, 95%CI [0.88; 1.83], p = 0.20) or prolonged antimicrobial therapy for more than 7 days (HR = 1.06, 95%CI [0.6; 1.86], p = 0.84). No differences were noted in in-hospital death irrespective of an appropriate and timely empiric antimicrobial therapy between mono- versus polymicrobial S. maltophilia HAP (p = 0.273). The duration of ventilation prior to S. maltophilia HAP diagnosis and ICU length of stay were shorter in patients with monomicrobial S. maltophilia HAP (p = 0.031 and p = 0.034 respectively).Conclusions: S. maltophilia HAP occurred in severe, long-stay intensive care patients who mainly required prolonged invasive ventilation. Empirical antimicrobial therapy was barely effective while antimicrobial treatment modalities had no significant impact on hospital survival.Trial registration: clinicaltrials.gov, NCT03506191

Effect of Tocilizumab vs Usual Care in Adults Hospitalized With COVID-19 and Moderate or Severe Pneumonia

International audienceImportance Severe pneumonia with hyperinflammation and elevated interleukin-6 is a common presentation of coronavirus disease 2019 (COVID-19).Objective To determine whether tocilizumab (TCZ) improves outcomes of patients hospitalized with moderate-to-severe COVID-19 pneumonia.Design, Setting, and Particpants This cohort-embedded, investigator-initiated, multicenter, open-label, bayesian randomized clinical trial investigating patients with COVID-19 and moderate or severe pneumonia requiring at least 3 L/min of oxygen but without ventilation or admission to the intensive care unit was conducted between March 31, 2020, to April 18, 2020, with follow-up through 28 days. Patients were recruited from 9 university hospitals in France. Analyses were performed on an intention-to-treat basis with no correction for multiplicity for secondary outcomes.Interventions Patients were randomly assigned to receive TCZ, 8 mg/kg, intravenously plus usual care on day 1 and on day 3 if clinically indicated (TCZ group) or to receive usual care alone (UC group). Usual care included antibiotic agents, antiviral agents, corticosteroids, vasopressor support, and anticoagulants.Main Outcomes and Measures Primary outcomes were scores higher than 5 on the World Health Organization 10-point Clinical Progression Scale (WHO-CPS) on day 4 and survival without need of ventilation (including noninvasive ventilation) at day 14. Secondary outcomes were clinical status assessed with the WHO-CPS scores at day 7 and day 14, overall survival, time to discharge, time to oxygen supply independency, biological factors such as C-reactive protein level, and adverse events.Results Of 131 patients, 64 patients were randomly assigned to the TCZ group and 67 to UC group; 1 patient in the TCZ group withdrew consent and was not included in the analysis. Of the 130 patients, 42 were women (32%), and median (interquartile range) age was 64 (57.1-74.3) years. In the TCZ group, 12 patients had a WHO-CPS score greater than 5 at day 4 vs 19 in the UC group (median posterior absolute risk difference [ARD] −9.0%; 90% credible interval [CrI], −21.0 to 3.1), with a posterior probability of negative ARD of 89.0% not achieving the 95% predefined efficacy threshold. At day 14, 12% (95% CI −28% to 4%) fewer patients needed noninvasive ventilation (NIV) or mechanical ventilation (MV) or died in the TCZ group than in the UC group (24% vs 36%, median posterior hazard ratio [HR] 0.58; 90% CrI, 0.33-1.00), with a posterior probability of HR less than 1 of 95.0%, achieving the predefined efficacy threshold. The HR for MV or death was 0.58 (90% CrI, 0.30 to 1.09). At day 28, 7 patients had died in the TCZ group and 8 in the UC group (adjusted HR, 0.92; 95% CI 0.33-2.53). Serious adverse events occurred in 20 (32%) patients in the TCZ group and 29 (43%) in the UC group (P = .21).Conclusions and Relevance In this randomized clinical trial of patients with COVID-19 and pneumonia requiring oxygen support but not admitted to the intensive care unit, TCZ did not reduce WHO-CPS scores lower than 5 at day 4 but might have reduced the risk of NIV, MV, or death by day 14. No difference on day 28 mortality was found. Further studies are necessary for confirming these preliminary results.Trial Registration ClinicalTrials.gov Identifier: NCT0433180

Effect of anakinra versus usual care in adults in hospital with COVID-19 and mild-to-moderate pneumonia (CORIMUNO-ANA-1): a randomised controlled trial

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Sarilumab in adults hospitalised with moderate-to-severe COVID-19 pneumonia (CORIMUNO-SARI-1): An open-label randomised controlled trial

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