Les facteurs de risque associés à la dépendance prolongée aux vasopresseurs en postopératoire de chirurgie cardiaque sous circulation extracorporelle

Introduction : La dépendance aux vasopresseurs est une complication fréquente de la chirurgie cardiaque. Le syndrome vasoplégique (SV) est une forme grave de dépendance aux vasopresseurs due soit à une réaction inflammatoire systémique diffuse, soit à un dysfonctionnement cardiaque après une séparation de la circulation extracorporelle (CEC). Bien que plusieurs facteurs de risque aient été décrits, aucune intervention n’a démontré d’efficacité pour prévenir cette complication. Objectif : Identifier les facteurs de risque modifiables de la dépendance prolongée aux vasopresseurs chez les patients ayant bénéficié d’une chirurgie cardiaque avec CEC. Devis : C’est une étude de cohorte, observationnelle, rétrospective et monocentrique ayant été menée à l’Institut de Cardiologie de Montréal. Patients et méthodes : Analyse rétrospective des patients provenant de deux études prospectives incluant 263 patients ayant subi une chirurgie cardiaque sous CEC entre 2015 et 2017 et admis aux soins intensifs (SI) de chirurgie cardiaque à l’Institut de Cardiologie de Montréal. L’étude exclut toutes les chirurgies cardiaques sans CEC, la transplantation cardiaque et les patients n’ayant pas reçu de vasopresseurs après la fin de la CEC. La dépendance prolongée aux vasopresseurs en postopératoire est définie par la persistance d’au moins un vasopresseur à partir de la fin de la CEC pour une durée supérieure à 24 heures. Une analyse de régression logistique fut effectuée afin de déterminer les variables indépendantes associées à la vasoplégie postopératoire. Résultats : Parmi les patients étudiés, 247 furent éligibles dont 98 (39,7 %) ont développé une dépendance prolongée aux vasopresseurs. Ces patients étaient plus âgés (67 ± 12 ans vs 64 ± 12 ans; p 30 et 55 mmHg (OR : 2,52, IC 95 % : 1,15-5,52) ; ou sévère si la PAPs est > 55 mmHg (OR : 8,12, IC 95 % : 2,54-26,03, p = 0,002)) et le bilan liquidien cumulatif des premières 24 h aux SI (OR : 1,76, IC 95 % : 1,32-2,33, p < 0,0001) étaient indépendamment associés au développement de la dépendance prolongée aux vasopresseurs. La prédiction du modèle était associée avec une aire sous la courbe ROC de 0,80, IC 95 % : 0,74-0,86, p < 0,0001. Conclusion : La dépendance prolongée aux vasopresseurs après une chirurgie cardiaque est une complication fréquente. La réduction de la FEVG, de l’HTP et un bilan hydrique positif se sont avérés des facteurs de risque indépendants dans ce contexte.Background: Vasopressor dependency is a common complication of cardiac surgery. The vasoplegic syndrome is a severe form of vasopressor dependency, due either to a diffuse systemic inflammatory reaction or to cardiac dysfunction after separation from cardiopulmonary bypass (CPB). Although several risk factors have been described, no intervention has been demonstrated to be effective to prevent this complication. The objective of this study is to identify modifiable pre and peri operative risk factors of prolonged vasopressor dependency after separation from CPB in cardiac surgery. Design: This is a retrospective observational study in a single specialized cardiac surgery center. Methods: A retrospective analysis of 263 patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) enrolled in two separate prospective studies was performed. Prolonged vasopressor use was defined as the persistence of at least one vasopressor for more than 24 hours after separation from CPB. Data collection included pre-operative risk factors, intraoperative treatment, hemodynamic and echocardiographic variables within the first 24 hours of intensive care unit (ICU) stay after surgery. Results: A total of 247 patients were included and 98 (39.7%) developed prolonged vasopressor dependence. Older age (67 ± 12 vs. 64 ± 12 years; p = 0.01) and higher EuroSCORE II (3.1% (IQR 1.7-6.1) vs. 1.7% (IQR 1.03-3.1); p < 0.0001) was associated with prolonged vasopressor dependence. Furthermore, those patients had worst outcomes including a longer duration of mechanical ventilation (5 hours (IQR 4-9) vs. 4 hours (IQR 3-5); p < 0.001) and a longer ICU stay (3 days (IQR 1-2) vs. 1 day (IQR 1-2); p < 0.001) and hospital stay (7 days (IQR 6-10) vs. 5 days (IQR 4-7)). Patients with prolonged vasopressor dependency had a longer CPB time (100 mins (IQR 75-129) vs. 83 mins (IQR 65-108); p = 0.009), greater intraoperative norepinephrine dose (0.07 ± 0.05 μg.kg-1.min-1 vs. 0.04 ± 0.04 μg.kg-1.min-1, p < 0.001) and larger fluid intake at the end of surgery (2747 ± 1241 vs. 2284 ± 879 ml; p = 0.001). In multivariable analysis, pre-existing reduced left ventricular ejection fraction (LVEF £ 30%) (OR: 9,52, 95 % CI : 1.14-79.24; p = 0.03), preoperative pulmonary hypertension (PH) (sPAP > 30 and £ 55 mmHg: OR: 2.5, 95 % CI : 1.14- 5.52; sPAP > 55 mmHg: OR: 8,12, 95 % CI: 2.53-26.02; p = 0.001) and first 24 hours cumulative fluid balance (OR: 1.78, 95 % CI: 1.41-2.24; p < 0.0001) were independently associated with the development of prolonged vasopressors dependence. This model had a good ability to predict prolonged vasopressor dependence after cardiac surgery (AUC = 0.80, 95 % CI: 0.73-0.86; p < 0.0001). Conclusions: Vasopressor dependency remains a frequent complication after CPB surgery. Its association with PH and positive fluid balance is unreported and potentially reversible. Prospective studies and clinical trials should explore the role and potential modulation of these two factors in order to prevent postoperative vasopressor dependency

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Plasma Exchange in the Management of Catastrophic Antiphospholipid Syndrome

Objective. Report of a case of catastrophic antiphospholipid syndrome (CAPS) with multiple organ involvement leading to a life-threatening condition despite early combination corticosteroid and heparin therapy. Initiation of plasma exchange led to rapid improvement of the patient’s general condition. Design. Case report. Setting. University teaching hospital medical intensive care unit. Patient. Single case: 52-year-old man hospitalized for catastrophic antiphospholipid syndrome (CAPS) with cardiac, renal, and cutaneous involvement. Despite early methylprednisolone and heparin therapy, the patient’s condition progressively deteriorated, resulting in acute renal failure, right adrenal hemorrhage, and pulmonary involvement, leading to acute respiratory distress on day 6, requiring high-flow nasal cannula oxygen therapy with FiO2 of 1.0. Interventions. Plasma exchange was started on day 6. Endpoints and Main Results. A marked improvement of the patient’s general condition was observed after initiation of plasma exchange, with successful weaning of oxygen therapy and normalization of platelet count, troponin, and serum creatinine within four days. Conclusions. This case illustrates the efficacy of plasma exchange in CAPS and the difficulty for physicians to determine the optimal timing of plasma exchange

Thrombotic Microangiopathy Revealing Bone Metastases from an Ethmoid Sinus Carcinoma

Cancer-related thrombotic microangiopathy (TMA) is a rare entity whose clinical and biological characteristics have been described in various tumors. Here we describe the first case of cancer-related TMA revealing diffuse bone metastases from an ethmoid sinus carcinoma

Urinary TIMP2 and IGFBP7 Identifies High Risk Patients of Short-Term Progression from Mild and Moderate to Severe Acute Kidney Injury during Septic Shock: A Prospective Cohort Study

Background. To examine whether the new urinary biomarkers TIMP2 and IGFBP7 can predict progression within 24 hours and 72 hours from mild and moderate (KDIGO 1 or 2) to severe (KDIGO 3) AKI in patients with septic shock. Methods. A prospective, multicenter observational study performed in three French ICUs. The urinary biomarkers TIMP2∗IGFBP7 were analyzed at the early phase (2.0 (ng/ml)2/1,000 identified the population at high risk of KDIGO 3 H24 (relative risk 4.19 (1.7-10.4)) with a sensitivity of 76% (60-87) and a specificity of 81% (69-89). But the diagnostic performance at H72 of baseline TIMP2∗IGFBP7 was poor (AUC: 0.69 (0.59-0.77)). Conclusion. The urinary TIMP2∗IGFBP7 concentration and the urine output at the early phase of septic shock are independent factors to identify the population at high risk of progression from mild and moderate to severe AKI over the next 24 but not 72 hours. A TIMP2∗IGFBP7 concentration>2.0 (ng/ml)2/1,000 quadruples the risk of KDIGO 3 AKI within 24 hours. This trial is registered with (NCT03547414)

Transthoracic echocardiography: an accurate and precise method for estimating cardiac output in the critically ill patient

Abstract Background Cardiac output (CO) monitoring is a valuable tool for the diagnosis and management of critically ill patients. In the critical care setting, few studies have evaluated the level of agreement between CO estimated by transthoracic echocardiography (CO-TTE) and that measured by the reference method, pulmonary artery catheter (CO-PAC). The objective of the present study was to evaluate the precision and accuracy of CO-TTE relative to CO-PAC and the ability of transthoracic echocardiography to track variations in CO, in critically ill mechanically ventilated patients. Methods Thirty-eight mechanically ventilated patients fitted with a PAC were included in a prospective observational study performed in a 16-bed university hospital ICU. CO-PAC was measured via intermittent thermodilution. Simultaneously, a second investigator used standard-view TTE to estimate CO-TTE as the product of stroke volume and the heart rate obtained during the measurement of the subaortic velocity time integral. Results Sixty-four pairs of CO-PAC and CO-TTE measurements were compared. The two measurements were significantly correlated (r = 0.95; p < 0.0001). The median bias was 0.2 L/min, the limits of agreement (LOAs) were –1.3 and 1.8 L/min, and the percentage error was 25%. The precision was 8% for CO-PAC and 9% for CO-TTE. Twenty-six pairs of ΔCO measurements were compared. There was a significant correlation between ΔCO-PAC and ΔCO-TTE (r = 0.92; p < 0.0001). The median bias was –0.1 L/min and the LOAs were –1.3 and +1.2 L/min. With a 15% exclusion zone, the four-quadrant plot had a concordance rate of 94%. With a 0.5 L/min exclusion zone, the polar plot had a mean polar angle of 1.0° and a percentage error LOAs of –26.8 to 28.8°. The concordance rate was 100% between 30 and –30°. When using CO-TTE to detect an increase in ΔCO-PAC of more than 10%, the area under the receiving operating characteristic curve (95% CI) was 0.82 (0.62–0.94) (p < 0.001). A ΔCO-TTE of more than 8% yielded a sensitivity of 88% and specificity of 66% for detecting a ΔCO-PAC of more than 10%. Conclusion In critically ill mechanically ventilated patients, CO-TTE is an accurate and precise method for estimating CO. Furthermore, CO-TTE can accurately track variations in CO

Non-invasive detection of a femoral-to-radial arterial pressure gradient in intensive care patients with vasoactive agents

International audienceAbstract Background In patient requiring vasopressors, the radial artery pressure may underestimate the true central aortic pressure leading to unnecessary interventions. When using a femoral and a radial arterial line, this femoral-to-radial arterial pressure gradient (FR-APG) can be detected. Our main objective was to assess the accuracy of non-invasive blood pressure (NIBP) measures; specifically, measuring the gradient between the NIBP obtained at the brachial artery and the radial artery pressure and calculating the non-invasive brachial-to-radial arterial pressure gradient (NIBR-APG) to detect an FR-APG. The secondary objective was to assess the prevalence of the FR-APG in a targeted sample of critically ill patients. Methods Adult patients in an intensive care unit requiring vasopressors and instrumented with a femoral and a radial artery line were selected. We recorded invasive radial and femoral arterial pressure, and brachial NIBP. Measurements were repeated each hour for 2 h. A significant FR-APG (our reference standard) was defined by either a mean arterial pressure (MAP) difference of more than 10 mmHg or a systolic arterial pressure (SAP) difference of more than 25 mmHg. The diagnostic accuracy of the NIBR-APG (our index test) to detect a significant FR-APG was estimated and the prevalence of an FR-APG was measured and correlated with the NIBR-APG. Results Eighty-one patients aged 68 [IQR 58–75] years and an SAPS2 score of 35 (SD 7) were included from which 228 measurements were obtained. A significant FR-APG occurred in 15 patients with a prevalence of 18.5% [95%CI 10.8–28.7%]. Diabetes was significantly associated with a significant FR-APG. The use of a 11 mmHg difference in MAP between the NIBP at the brachial artery and the MAP of the radial artery led to a specificity of 92% [67; 100], a sensitivity of 100% [95%CI 83; 100] and an AUC ROC of 0.93 [95%CI 0.81–0.99] to detect a significant FR-APG. SAP and MAP FR-APG correlated with SAP ( r 2 = 0.36; p < 0.001) and MAP ( r 2 = 0.34; p < 0.001) NIBR-APG. Conclusion NIBR-APG assessment can be used to detect a significant FR-APG which occur in one in every five critically ill patients requiring vasoactive agents