Analgésie morphinique périmédullaire (complications respiratoires après césarienne programmée)

CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Non-invasive ventilation indication for critically ill cancer patients admitted to the intensive care unit for acute respiratory failure (ARF) with associated cardiac dysfunction: Results from an observational study.

BackgroundAcute respiratory failure (ARF) is a life-threatening complication in onco-hematology patients. Optimal ventilation strategy in immunocompromised patients has been highly controversial over the last decade. Data are lacking on patients presenting with ARF associating isolated cardiac dysfunction or in combination with another etiology. The aim of this study was to assess prognostic impact of initial ventilation strategy in onco-hematology patients presenting ARF with associated cardiac dysfunction.MethodsWe conducted an observational retrospective study in Institut Paoli-Calmettes, a cancer-referral center, assessing all critically ill cancer patients admitted to the ICU for a ARF with cardiac dysfunction.ResultsBetween 2010-2017, 127 patients were admitted. ICU and hospital mortality were 29% and 57%. Initial ventilation strategy was invasive mechanical ventilation (MV) in 21%. Others ventilation strategies were noninvasive ventilation (NIV) in 50%, associated with oxygen in 21% and high flow nasal oxygen (HFNO) in 29%, HFNO alone in 6% and standard oxygen in 23%. During ICU stay, 48% of patients required intubation. Multivariate analysis identified 3 independent factors associated with ICU mortality: SAPSII at admission (OR = 1.07/point, 95%CI = 1.03-1.11, pConclusionIn onco-hematology patients admitted for ARF with associated cardiac dysfunction, severity at ICU admission, invasive fungal infections and initial ventilation strategy were independently associated with ICU mortality. NIV was a protective factor on ICU mortality

Successful Imatinib Treatment of an Abdominal Compartment Syndrome due to Huge Gastrointestinal Stromal Tumour

International audienceGastrointestinal stromal tumours (GISTs) are the most common digestive mesenchymal tumours, whose prognosis has been revolutionised by targeted therapies such as oral imatinib. Abdomen compartment syndrome (ACS) is associated with mortality superior to 50% in adults. ACS has never been reported to date in patients with GIST. Specific anticancer treatment in critically ill patients in intensive care unit (ICU) remains a matter of debate given the high mortality rate. Here, we report the case of a 58-year-old woman with ACS related to a 40-cm huge GIST and multi-organ failure requiring mechanical ventilation, vasopressive support and haemodialysis. She was treated in emergency with imatinib via the naso-gastric tube (day 1), then at day 3 by decompressive laparotomy and "open abdomen" without any tumour removal. Imaging after 11 days imatinib showed objective tumour response. Because of improvement of multi-organ dysfunctions, the laparotomy was closed at day 14, and the resuscitation procedures were progressively stopped. After discharge from hospital, she survived nearly two years. This is the first case of successful treatment of cancer-associated ACS by targeted therapy and decompressive laparotomy. Imatinib in critically ill patients with GIST may be successful even in presence of multi-organ failure

Protective effect of early low-dose hydrocortisone on ventilator-associated pneumonia in the cancer patients: a propensity score analysis

International audienceVentilator-associated pneumonia (VAP) is a care-related event that could be promoted by immune suppression caused by critical diseases, malignancies and cancer treatments. Low dose of hydrocortisone was proposed for modulation of immune response in the critically ill population. In this monocentric observational study, all cancer patients mechanically ventilated for more than 48 h were included. Effect of low-dose hydrocortisone administered during the first 48 h of mechanical ventilation was evaluated applying inverse probability weighting analysis after propensity score assessment. VAP impact on 1-year mortality, ICU length of stay and mechanical ventilation duration was secondarily determined. Within this cohort, 190 cancer patients were followed. VAP was confirmed in 22.1% of cases in the early hydrocortisone group and confirmed in 42.6% of cases in the no or late hydrocortisone group. Early hydrocortisone exhibited a protective effect on the risk of VAP (OR 0.23; 95% CI 0.12-0.44; P < 0.0001). VAP was associated with 1-year mortality (HR 1.60; 95% CI 1.10-2.34; P = 0.017) and increased ICU length of stay (mean extra length of stay: 4.2 days; 95% CI 0.6-7.8). Immune modulation with low-dose hydrocortisone administered in the first days of mechanical ventilation could protect from VAP occurrence in cancer patients

Impact of a computer-assisted decision support system (CDSS) on nutrition management in critically ill hematology patients: the NUTCHOCO study (nutritional care in hematology oncologic patients and critical outcome)

International audienceBackground: Mortality of critically ill hematology (HM) patients has improved over time. Thus, those patients require an extensive diagnostic workup and the optimal use of available treatments. There are no data regarding nutrition strategy for critically ill HM patients, while nutritional support is crucial for both HM and critically ill patients. We hypothesized that the implementation of a computer-assisted decision support system (CDSS), designed to supervise a nutritional intervention by a multidisciplinary team, would be able to increase guidelines adherence and outcomes. Results: In this before/after study, 275 critically ill hematology patients admitted to the ICU over 5-year period were included. Energy and protein intakes were delivered using standard protocol in the 147 patients (53%) of the 'before group' and using a CDSS in order to reach every day predefined caloric and protein targets accordingly to the cata-bolic or anabolic status in the 128 patients (47%) of the 'after group. ' Using a Poisson regression, we showed that the use of CDSS allowed to reach a relative increase in the rate of days in compliance with caloric (1.57; 95% confidence interval (CI), [1.17-2.10], p = 0.0025) and protein targets (3.86 [2.21-6.73], p < 0.0001) in the 'after group' by more than 50% as compared with the 'before group. ' Interestingly, compliance rates were low and only reached 30% after intervention. Hospital mortality, ICU-acquired infection, and hospital, and ICU length of stay were similar in the two groups of patients. Importantly, exploratory analysis showed that hospital mortality was lower in the 'after group' for neutro-penic and severely ill patients. Conclusion: For critically ill hematology patients, the use of a nutritional CDSS allowed to increase the days in compliance with caloric and protein targets as compared with no CDSS use. In this context, overall hospital mortality was not affected. © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made

Respiratory events in ward are associated with later intensive care unit (ICU) admission and hospital mortality in onco-hematology patients not admitted to ICU after a first request

<div><p>Introduction</p><p>Prognostic impact of delayed intensive care unit(ICU) admission in critically ill cancer patients remains debatable. We determined predictive factors for later ICU admission and mortality in cancer patients initially not admitted after their first ICU request.</p><p>Methods</p><p>All cancer patients referred for an emergency ICU admission between 1 January 2012 and 31 August 2013 were included.</p><p>Results</p><p>Totally, 246(54.8%) patients were immediately admitted. Among 203(45.2%) patients denied at the first request, 54(26.6%) were admitted later. A former ICU stay [OR: 2.75(1.12–6.75)], a request based on a clinical respiratory event[OR: 2.6(1.35–5.02)] and neutropenia[OR: 2.25(1.06–4.8)] were independently associated with later ICU admission. Survival of patients admitted immediately and later did not differ at ICU(78.5% and 70.4%, respectively; <i>p</i> = 0.2) or hospital(74% and 66%, respectively; <i>p</i> = 0.24) discharge. Hospital mortality of patients initially not admitted was 29.7% and independently associated with malignancy progression[OR: 3.15(1.6–6.19)], allogeneic hematopoietic stem cell transplantation[OR: 2.5(1.06–5.89)], a request based on a clinical respiratory event[OR: 2.36(1.22–4.56)] and severe sepsis[OR: 0.27(0.08–0.99)].</p><p>Conclusion</p><p>Compared with immediate ICU admission, later ICU admission was not associated with hospital mortality. Clinical respiratory events were independently associated with both later ICU admission and hospital mortality.</p></div

Kaplan-Meier survival curves of « immediate admission » and « later admission » groups.

<p>Kaplan-Meier survival curves of « immediate admission » and « later admission » groups.</p