Respiratory pulse pressure variation fails to predict fluid responsiveness in acute respiratory distress syndrome

International audienceIntroduction: Fluid responsiveness prediction is of utmost interest during acute respiratory distress syndrome (ARDS), but the performance of respiratory pulse pressure variation (Δ RESP PP) has scarcely been reported. In patients with ARDS, the pathophysiology of Δ RESP PP may differ from that of healthy lungs because of low tidal volume (Vt), high respiratory rate, decreased lung and sometimes chest wall compliance, which increase alveolar and/or pleural pressure. We aimed to assess Δ RESP PP in a large ARDS population. Methods: Our study population of nonarrhythmic ARDS patients without inspiratory effort were considered responders if their cardiac output increased by >10% after 500-ml volume expansion. Results: Among the 65 included patients (26 responders), the area under the receiver-operating curve (AUC) for Δ RESP PP was 0.75 (95% confidence interval (CI 95): 0.62 to 0.85), and a best cutoff of 5% yielded positive and negative likelihood ratios of 4.8 (CI 95 : 3.6 to 6.2) and 0.32 (CI 95 : 0.1 to 0.8), respectively. Adjusting Δ RESP PP for Vt, airway driving pressure or respiratory variations in pulmonary artery occlusion pressure (ΔPAOP), a surrogate for pleural pressure variations, in 33 Swan-Ganz catheter carriers did not markedly improve its predictive performance. In patients with ΔPAOP above its median value (4 mmHg), AUC for Δ RESP PP was 1 (CI 95 : 0.73 to 1) as compared with 0.79 (CI 95 : 0.52 to 0.94) otherwise (P = 0.07). A 300-ml volume expansion induced a ≥2 mmHg increase of central venous pressure, suggesting a change in cardiac preload, in 40 patients, but none of the 28 of 40 nonresponders responded to an additional 200-ml volume expansion. Conclusions: During protective mechanical ventilation for early ARDS, partly because of insufficient changes in pleural pressure, Δ RESP PP performance was poor. Careful fluid challenges may be a safe alternative

Echographie versus IRM pour la mesure de la lumière laryngée cricoïdienne (étude chez le volontaire sain)

TOURS-BU Médecine (372612103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Mesure non invasive de la pression artérielle chez le patient de réanimation (performance selon le site de mesure)

Introduction: En réanimation, la pression artérielle (PA) est régulièrement mesurée de façon non invasive, y compris chez le patient souffrant d'insuffisance circulatoire aigue (ICA), dans l'attente de la pose d'un cathéter artériel. Le brassard est parfois placé sur la cheville ou la cuisse en raison de l'impossibilité de le positionner autour du bras, mais aucune étude n'a évalué cette pratique. Nous avons donc étudié la fiabilité de la mesure non invasive de la PA en ces différents sites. Matériel et méthodes: Dans cette étude prospective, des patients hospitalisés en réanimation ont été inclus s'ils étaient porteurs d'un cathéter artériel et ne souffraient pas d'artériopathie oblitérante évoluée. En cas de douleur marquée provoquée par le gonflage du brassard, le patient était exclu. Pour chaque site (bras, cheville et cuisse [uniquement si score de Ramsay>4]), une série de 3 paires de mesures invasives et non invasives de la PA a été réalisée. Les patients souffrant d'ICA ont fait l'objet d'une 2e série de mesures après intervention hémodynamique (remplissage vasculaire et/ou modification de dose de catécholamines). Résultats: Sur les 159 patients inclus, 9 ont été exclus (artériopathie, douleur), 79 étaient en ICA (dont 57 ayant bénéficié d'une intervention hémodynamique). La mesure non invasive a échoué aux 3 sites chez un même patient, et à la cuisse chez un autre. Quel que soit le site de mesure, la concordance entre mesures invasives et non invasives était meilleure pour la P AM que pour la PAS ou la PAD où elle était médiocre. La mesure non invasive de la PAM était fiable au bras (biais moyen de 3,4+-5 mmHg), validant les critères recommandés, contrairement à la cheville et la cuisse (biais moyen de 3,1+-7,7 et 5,7+-6,8 mmHg, respectivement). En revanche, chez le patient souffrant d'ICA, la mesure à la cheville et à la cuisse permettait une bonne détection 1) d'une PAM 10% (ASC de 0,99 [0,92-1], 0,90 [0,80-0,97] et 0,96 [0,87-0,99], respectivement). Conclusion: Dans notre population de patients de réanimation, seule la valeur de la PAM mesurée au bras est fiable, y compris en cas d'insuffisance circulatoire aigue. En cas d'impossibilité de positionner le brassard au niveau du bras, la cheville et la cuisse peuvent être des alternatives fiables, afin de détecter les patients souffrant d'hypotension artérielle et pour identifier les répondeurs à une intervention hémodynamique, dans l'attente de la pose d'un cathéter artériel.MONTPELLIER-BU Médecine UPM (341722108) / SudocMONTPELLIER-BU Médecine (341722104) / SudocSudocFranceF

Épidémiologie de la néphropathie induite par les produits de contraste iodés chez le patient de réanimation (étude prospective)

MONTPELLIER-BU Médecine UPM (341722108) / SudocMONTPELLIER-BU Médecine (341722104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Dynamic Indices Derived from Heart–Lung Interactions: Incende Quod Adorasti

International audienc

Lack of impact of iodinated contrast media on kidney cell-cycle arrest biomarkers in critically ill patients

Abstract Background Iodinated contrast media may contribute to acute kidney injury. However, several recent works suggest that this toxicity is minimal in the clinical setting. Recently, urinary G1 cell-cycle arrest proteins tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin like growth factor binding protein 7 (IGFBP-7) were identified as highly sensitive and specific biomarkers for early detection of kidney aggression. The impact of contrast administration on those biomarkers has not been specifically evaluated but could provide clues about the toxicity of contrast media. This study aimed at measuring changes in TIMP-2 and IGFBP-7 urinary concentrations before and after a contrast-enhanced computed tomography in critically ill patients. Methods 77 patients were included in a prospective observational cohort study. Urinary [TIMP -2]·[IGFBP-7] was measured before, 6 and 24 h after contrast infusion. Urine output and serum creatinine were followed 3 days. Results Median [TIMP-2]·[IGFBP-7] was 0.06 [interquartile range 0.04;0.26], 0.07 [0.03;0.34] and 0.10 [0.04;0.37] (ng/mL)2/1000 respectively before, 6 and 24 h after contrast infusion. Individual changes from baseline were − 0.01 [− 0.11;0.11] and 0.00 [− 0.10;0.09] (ng/ml)2/1000 at 6 and 24 h. These changes were not higher among the patients increasing their Kidney Disease Improving Global Outcome (KDIGO) classification within 3 days after contrast infusion (n = 14 [18%] based on creatinine criterion only, n = 42 [55%] based on creatinine and urine output). Conclusions Changes in [TIMP-2]·[IGFBP-7] urinary concentration after contrast-enhanced computed tomography were insignificant, suggesting minimal kidney aggression by modern iodinated contrast media

Evolution of Neurological Recovery during the First Year after Subarachnoid Haemorrhage in a French University Centre

International audienceINTRODUCTION: The evolution of neurological recovery during the first year after aneurysmal Subarachnoid Haemorrhage (SAH) is poorly described. PATIENTS: Patients with SAH in one university hospital from March the 1st 2010, to December 31st 2012, with a one-year follow-up. METHOD: Evaluation was performed via phone call at 3, 6 and 12\,months. Primary endpoint was poor neurological recovery (modified Rankin Scale 3-4-5-6), one year after SAH. Secondary endpoints were the incidence of lack of self-perceived previous health status recovery and incidence of cognitive disorders, one year after SAH. Risk factors of poor neurological recovery were retrieved with multivariable logistic regression. RESULTS: Two hundred and eleven patients were included and 208 had a complete follow-up. One hundred and twenty (57.7%) patients were female, 112 (53.8%) had a WFNS grade I-II-III. Seventy (33.6%) patients displayed one-year poor neurological outcome and risk factors of poor outcome were age, baseline Glasgow Coma Score\,≤q\,8, external ventricular drainage, intra-cranial hypertension and angiographic vasospasm. We observed an improvement in good outcome at 3\,months [112 (53.8%) patients], 6 months [127 (61.1%) patients] and one-year [138 (66.3%) patients]. Fifty-nine (35.3%) patients recovered previous health status, 96 (57.5%) had persistent behaviour disorders, and 71 (42.5%) suffered from memory losses at one year. DISCUSSION: Neurological recovery seems to improve over time. The same key complications should be targeted worldwide in SAH patients. CONCLUSION: Neurological complications in the following of SAH should be actively treated in order to improve outcome. The early neuro-ICU phase remains a key determinant of long-term recovery