Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: Observational study of neurological and infectious outcomes

AbstractIntroductionNeuromuscular blockade (NMB) is widely used during therapeutic hypothermia (TH) after cardiac arrest but its effect on patient outcomes is unclear. We compared the effects of NMB on neurological outcomes and frequency of early-onset pneumonia in cardiac-arrest survivors managed with TH.MethodsWe retrospectively studied consecutive adult cardiac-arrest survivors managed with TH in a tertiary-level intensive care unit between January 2008 and July 2013. Patients given continuous NMB for persistent shivering were compared to those managed without NMB. Cases of early-onset pneumonia and vital status at ICU discharge were recorded. To avoid bias due to between-group baseline differences, we adjusted the analysis on a propensity score.ResultsOf 311 cardiac-arrest survivors, 144 received TH, including 117 with continuous NMB and 27 without NMBs. ICU mortality was lower with NMB (hazard ratio [HR], 0.54 [0.32; 0.89], p=0.016) but the difference was not significant after adjustment on the propensity score (HR, 0.70 [0.39; 1.25], p=0.22). The proportion of patients with good neurological outcomes was not significantly different (36% with and 22% without NMB, p=0.16). Early-onset pneumonia was more common with NMB (HR, 2.36 [1.24; 4.50], p=0.009) but the difference was not significant after adjustment on the propensity score (HR, 1.68 [0.90; 3.16], p=0.10).ConclusionsContinuous intravenous NMB during TH after cardiac arrest has potential owns effects on ICU survival with a trend increase in the frequency of early-onset pneumonia. Randomised controlled trials are needed to define the role for NMB among treatments for TH-induced shivering

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/)

Sonde d' intubation endotrachéale et pneumopathies acquises sous ventilation mécanique : physiopathogénie et moyens de prévention

Les pneumopathies acquises sous ventilation mécanique (PAVM) restent une cause majeure de morbi-mortalité en réanimation. La présence, pourtant indispensable, de la sonde d intubation endotrachéale (IET) joue un rôle pivot dans la physiopathologie de leur survenue. Ainsi, différentes stratégies de prévention des PAVM ciblées sur des modifications de la sonde d IET ont vu le jour. Parmi ces modifications, la possibilité de drainer les sécrétions accumulées dans l'espace sous-glottique est une avancée intéressante. Dans l'étude multicentrique randomisée rapportée dans ce travail de thèse et incluant 333 patients, le drainage des sécrétions sous-glottiques est, ainsi, associé à une réduction relative de 42,2% de l incidence des PAVM, avec un effet préventif concernant les PAVM précoces et tardives. Les autres progrès potentiels concernent la mise au point de ballonnets en polyuréthane ou en silicone, garants d une meilleure étanchéité des voies aériennes, celle de sondes d IET imprégnées d antiseptiques et la conception de sondes d'IET regroupant plusieurs stratégies de prévention. Leur évaluation, soit trop préliminaire, soit sujette à caution ne permet pas de recommander à ce jour leur usage en pratique clinique. Pourtant, l avenir réside probablement dans l optimisation de la sonde d IET de réanimation, combinant ces différents éléments et adaptée à chaque individu. Enfin, la prévention des PAVM, au sein d'un service de réanimation, ne se conçoit que dans la mise en place et le suivi d'une stratégie globale et multifactorielle adoptée par l'ensemble des soignants pour rendre son application, jour après jour, réellement effective.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Du bon usage des antibiotiques: évaluation des pratiques au sein d'un service d'accueil et d'urgence (étude observationnelle)

ST QUENTIN EN YVELINES-BU (782972101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Hémorragies digestives hautes admises en réanimation pendant les horaires de garde (évaluation d'un algorithme décisionnel. Etude de type avant-après)

La prise en charge des hémorragies digestives hautes, en dehors de la correction de l'hypovolémie, de l'anémie et des troubles de l'hémostase, associe un traitement médicamenteux (antisécrétoires et analogues de la somatostatine) et la réalisation d'une fibroscopie oesogastroduodénale (FOGD) diagnostique et thérapeutique. Pour les patients admis dans la journée, celle-ci est généralement pratiquée dans les heures suivant l'admission en réanimation. Pour les patients admis pendant les horaires de garde, se pose souvent la question de la réalisation d'une FOGD en urgence ou différée au lendemain. Dans le cadre de l'astreinte endoscopique du Centre Hospitalier de Poissy, un algorithme décisionnel a été élaboré, pour rationaliser l'indication, urgente ou différée, de la FOGD dans les hémorragies digestives hautes admises en réanimation pendant la garde. A l'admission en réanimation, les patients sont répartis en quatre catégories de gravité croissante : A (bonne tolérance clinique) et B1 (mauvaise tolérance clinique initiale mais amélioration après trois heures de traitement médicamenteux) : FOGD différée ; B2 (mauvaise tolérance clinique persistante) et C (choc hémorragique) : FOGD urgente. L'évaluation de cette procédure a fait l'objet d'une étude de type avant - après d'avril 1997 à mars 2001 incluant 137 patients admis en réanimation (64 avant, 73 après l'instauration de la procédure). Pour chaque catégorie, les caractéristiques clinique et biologiques des patients se sont avérées comparables entre les deux périodes d'évaluation. L'algorithme décisionnel a permis de réduire de manière significative le nombre de FOGD réalisées en urgence en garde. Cette réduction porte essentiellement sur les patients initialement instables mais s'améliorant après trois heures de traitement médicamenteux (64,3%) avant la procédure versus 9,4% après (p < 0,001)). L'instauration de cet algorithme décisionnel n'a pas eu d'impact sur la morbi-mortalité, évaluée sur la récidive hémorragique dans les 72 heures, la nécessité d'une deuxième FOGD en urgence, le nombre de culots globulaires et la mortalitéPARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

An Overview of Hypoglycemia in the Critically Ill

Hypoglycemia is a common and serious problem among patients with diabetes mellitus. It is also perceived as the most important obstacle to tight glucose control using intensive insulin therapy in critically ill patients. Because glucose is an obligatory metabolic fuel for the brain, hypoglycemia always represents an emergency that signals the inability of the brain to meet its energy needs. When left untreated, hypoglycemia can result in permanent brain damage and ultimately, death. In the context of critical illness that limits endogenous glucose production and increases glucose utilization, inadequate nutrition, or insufficient provision of glucose, intensive insulin therapy is the most frequent cause of hypoglycemia. Neurogenic and neuroglycopenic symptoms of hypoglycemia can remain unknown because of the underlying critical illness and sedation. Thus, close and reliable monitoring of the glycemic level is crucial in detecting hypoglycemia. In prospective randomized controlled studies comparing the effects of two glucose regimens, intensive insulin therapy aimed to reach strict glucose control (<110 mg/dl) but increased the incidence of severe hypoglycemia (<40 mg/dl) by four- to sixfold. Severe hypoglycemia is statistically associated with adverse outcomes in intensive care unit patients, although a direct causal relationship has not been demonstrated

Is copd associated with increased risk for microaspiration in intubated critically ill patients ?

International audienceBACKGROUND: Although COPD patients are at higher risk for aspiration when breathing spontaneously, no information is available on the risk for microaspiration in invasively ventilated COPD patients. The aim of our study was to determine the relationship between COPD and abundant microaspiration in intubated critically ill patients.METHODS: This was a retrospective analysis of prospectively collected data, provided by 3 randomized controlled trials on microaspiration in critically ill patients receiving invasive mechanical ventilation for more than 48 h. Abundant microaspiration was defined as the presence of pepsin and or alpha-amylase at significant levels in tracheal aspirates. In all study patients, pepsin and alpha-amylase were quantitatively measured in all tracheal aspirates collected during a 48-h period. COPD was defined using spirometry criteria.RESULTS: Among the 515 included patients, 70 (14%) had proven COPD. Pepsin and alpha-amylase were quantitatively measured in 3873 and 3764 tracheal aspirates, respectively. No significant difference was found in abundant microaspiration rate between COPD and non-COPD patients (62 of 70 patients (89%) vs 366 of 445 (82%) patients, p = 0.25). Similarly, no significant difference was found in abundant microaspiration of gastric contents (53% vs 45%, p = 0.28), oropharyngeal secretions (71% vs 71%, p = 0.99), or VAP (19% vs 22%, p = 0.65) rates between the two groups. No significant difference was found between COPD and non-COPD patients in duration of mechanical ventilation, ICU length of stay, or ICU mortality.CONCLUSIONS: Our results suggest that COPD is not associated with increased risk for abundant microaspiration in intubated critically ill patients

Early versus differed arterial catheterisation in critically ill patients with acute circulatory failure: a multicentre, open-label, pragmatic, randomised, non-inferiority controlled trial: the EVERDAC protocol

International audienceIntroduction: The use of peripheral indwelling arterial catheter for haemodynamic monitoring is widespread in the intensive care unit and is recommended in patients with shock. However, there is no evidence that the arterial catheter could improve patient's outcome, whereas the burden of morbidity generated is significant (pain, thrombosis, infections). We hypothesise that patients with shock may be managed without an arterial catheter.Methods and analysis: The EVERDAC study is an investigator-initiated, pragmatic, multicentre, randomised, controlled, open-label, non-inferiority clinical trial, comparing a less invasive intervention (ie, no arterial catheter insertion until felt absolutely needed, according to predefined safety criteria) or usual care (ie, systematic arterial catheter insertion in the early hours of shock). 1010 patients will be randomised with a 1:1 ratio in two groups according to the strategy. The primary outcome is all-cause mortality by 28 days after inclusion. A health economic analysis will be carried out.Ethics and dissemination: The study has been approved by the Ethics Committee (Comité de Protection des Personnes Île de France V, registration number 61606 CAT 2, 19 july 2018) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.Trial registration number: NCT03680963

Relationship between obesity and ventilator-associated pneumonia: a post-hoc analysis of the NUTRIREA2 trial.

International audiencePatients with obesity are at higher risk for community-acquired and nosocomial infections. However, no study has specifically evaluated the relationship between obesity and ventilator-associated pneumonia (VAP)