Intubation in the ICU

International audienc

Oxygénothérapie à haut débit, oxygénation apnéique et intubation en anesthésie

International audienceL’oxygénothérapie à haut débit est un dispositif qui permet de délivrer un gaz à haut débit par voie nasale. Ce gaz est réchauffé et humidifié et sa fraction inspirée en oxygène est réglable. Les effets physiologiques sont nombreux : lavage de l’espace mort anatomique, stabilité de la fraction inspirée en oxygène, préservation de la muqueuse et de la clairance mucociliaire. Ces effets physiologiques expliquent les bénéfices cliniques constatés : amélioration des échanges gazeux, baisse du travail respiratoire, confort optimisé pour le patient. L’oxygénation apnéique est un phénomène physiologique bien décrit qui permet une augmentation de la durée d’apnée sans désaturation. C’est une explication de l’efficacité de l’OHD pendant l’induction anesthésique. L’oxygénation apnéique par OHD a montré son intérêt chez les patients à risque d’intubation difficile, dans l’intubation en séquence rapide mais également chez les femmes enceintes. Chez les patients obèses en préoxygénation combinée avec oxygénation apnéique elle est moins efficace que la ventilation non invasive (VNI). L’objectif de cette revue est de résumer les connaissances actuelles sur l’OHD au bloc opératoire, plus précisément pour son utilisation dans la préoxygénation et l’oxygénation apnéique

Oxygénothérapie à haut débit en périopératoire : quelles données ?

International audienceMore than 10 % of surgical patients will present at least one postoperative pulmonary complication. The more patients have comorbidities and the longer and more invasive the surgery, the greater the risk of pulmonary complications. High-Flow Nasal Oxygen Therapy (HFNO) is a device that delivers inspiratory gas heated and humidified through a nasal cannula at higher flow rates than conventional oxygen therapy (up to 70 L/min), with an inspired fraction in oxygen (FiO2) which can vary from 21 % to 100 %. At the physiological level, HFNO improves oxygenation, increases expiratory resistance (responsible for a modest “Positive Expiratory Pressure effect” (PEP)), presents an anatomical dead space washing effect, improves mucociliary clearance and decreases the metabolic cost of respiration by providing warmed and humidified inspiratory gas. HFNO has been proposed for the operating theatre intubation procedure. It is not as effective as the bag valve mask method for pre-oxygenation. However, it can allow apnoeic oxygenation after the patient has lost spontaneous ventilation, without replacing bag valve mask ventilation in the event of desaturation. HFNO can be used for some procedures without intubation, such as oropharyngeal surgery, gastrointestinal endoscopy or electroconvulsive therapy. Apnoeic oxygenation is effective in these situations to prevent desaturation. Perioperatively, HFNO can be used for the prevention of acute postoperative respiratory distress, particularly in hypoxemic patients who cannot tolerate non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP). If acute postoperative respiratory distress occurs, a surgical complication should be eliminated. NIV remains the gold standard nowadays, even though HFNO has shown its non-inferiority after cardiothoracic surgery.Plus de 10 % des patients chirurgicaux vont présenter au moins une complication pulmonaire postopératoire. Plus les patients ont des comorbidités et plus la chirurgie est longue et invasive, plus le risque de complications pulmonaires augmente. L’oxygénothérapie nasale à haut débit (OHD) est un dispositif qui fournit un gaz inspiratoire chauffé et humidifié par une canule nasale à des débits plus élevés que l’oxygénothérapie conventionnelle (jusqu’à 70 L/min), avec une fraction inspirée en oxygène (FiO2) pouvant varier de 21 % à 100 %. Au niveau physiologique, l’OHD améliore l’oxygénation, augmente les résistances expiratoires (responsable d’un modeste « effet Pression Expiratoire Positive » (PEP)), présente un effet lavage d’espace mort anatomique, améliore la clairance muco-ciliaire et diminue le coût métabolique de la respiration en fournissant un gaz inspiratoire réchauffé et humidifié. L’OHD a été proposée pour la procédure d’intubation au bloc opératoire. Seule, elle n’est pas aussi efficace que la méthode au masque pour la préoxygénation. Elle permet une oxygénation apnéique après la perte de la ventilation spontanée du patient, sans remplacer la ventilation au ballon en cas de désaturation. L’OHD peut être utilisée pour certaines procédures sans intubation, comme la chirurgie oro-pharyngée, l’endoscopie digestive ou l’électroconvulsivothérapie. L’oxygénation apnéique est efficace dans ces situations pour prévenir la désaturation. En périopératoire, l’OHD peut être utilisée pour la prévention de la détresse respiratoire aiguë postopératoire, notamment chez le patient hypoxémique ne tolérant pas la ventilation non invasive (VNI) ou la pression positive continue (continuous positive airway pressure, CPAP). En cas de survenue d’une détresse respiratoire aiguë postopératoire, une complication chirurgicale devra être éliminée. La VNI reste aujourd’hui la technique de référence, même si l’OHD a montré sa non-infériorité après chirurgie cardiothoraciqu

Délirium en réanimation : épidémiologie et prise en charge

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Outcomes and time trends of acute respiratory distress syndrome patients with and without liver cirrhosis: an observational cohort

Abstract Background In studies prior to lung-protective ventilation, liver cirrhosis in acute respiratory distress syndrome (ARDS) was associated with high mortality rates. Since patients with cirrhosis have been excluded from many trials on ARDS, their outcome when treated with lung-protective ventilation is unclear. The objectives were to assess whether cirrhosis is associated with mortality in ARDS and trends over time in mortality and severity. Methods We conducted a retrospective analysis of a prospective observational cohort conducted in a 20-bed tertiary ICU from October 2003 to December 2021. All consecutive adult critically ill patients with ARDS were included. ARDS was defined by the Berlin criteria. The primary outcome was 90 day mortality, assessed with Kaplan–Meier curves and multivariate Cox analysis. Time trends were assessed on 90 day mortality, Sequential Organ-Function Assessment score (SOFA) and non-hepatic SOFA. Ventilation settings were compared between patients with and without cirrhosis. Results Of the 7155 patients screened, 863 had a diagnosis of ARDS. Among these ARDS patients, 157(18%) had cirrhosis. The overall 90 day mortality was of 43% (378/863), 57% (90/157) in patients with cirrhosis and 41% (288/706) in patients without cirrhosis (p < 0.001). On survival curves, cirrhosis was associated with 90 day mortality (p < 0.001). Cirrhosis was independently associated with 90 day mortality in multivariate analysis (hazard ratio = 1.56, 95% confidence interval 1.20–2.02). There was no change in mortality over time in ARDS patients with and without cirrhosis. SOFA (p = 0.04) and non-hepatic SOFA (p = 0.02) increased over time in ARDS patients without cirrhosis, and remained stable in ARDS patients with cirrhosis. Tidal volume, positive end-expiratory pressure, plateau pressure and driving pressure were not different between ARDS patients with and without cirrhosis. Conclusions Although ARDS management improved over the last decades, the 90 day mortality remained high and stable over time for both ARDS patients with (57%) and without cirrhosis (41%). Nevertheless, the severity of patients without cirrhosis has increased over time, while the severity of patients with cirrhosis has remained stable. Graphical Abstrac

Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis

International audienceBackground: In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement.Methods: In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome (P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P value <.01 was considered statistically significant).Results: Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94-1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10-2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57-1.02; P = .02).Conclusions: In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function

Adverse events, short- and long-term outcomes of extra corporeal liver therapy in the intensive care unit: 16 years experience with MARS® in a single center

International audienceAbstract Background Molecular Adsorbent Recirculating System (MARS®) is a non-biological artificial liver device. The benefit risk ratio between uncertain clinical effects and potential adverse events remains difficult to assess. We sought to describe adverse events related to MARS® therapy as well as biological and clinical effects. Methods All intensive care unit (ICU) admissions to whom MARS® therapy was prescribed from March 2005 to August 2021 were consecutively and prospectively included. The main endpoint was the incidence of adverse events related to MARS® therapy. Secondary endpoints were the biological and clinical effects of MARS® therapy. Results We reported 180 admissions treated with MARS® therapy. Among the 180 admissions, 56 (31.1%) were for acute-on-chronic liver failure, 32 (17.8%) for acute liver failure, 28 (15.5%) for post-surgery liver failure, 52 (28.9%) for pruritus and 12 (6.7%) for drug intoxication. At least one adverse event occurred in 95 (52.8%) admissions. Thrombocytopenia was the most frequent adverse event which was recorded in 55 admissions (30.6%). Overall, platelets count was 131 (± 95) × 10 9 /L before and 106 (± 72) × 10 9 /L after MARS® therapy ( p < .001). After MARS® therapy, total bilirubin was significantly decreased in all groups ( p < 0.05). Hepatic encephalopathy significantly improved in both the acute-on-chronic and in the acute liver failure group ( p = 0.01). In the pruritus group, pruritus intensity score was significantly decreased after MARS® therapy ( p < 0.01). Conclusion In this large cohort of patients treated with MARS® therapy we report frequent adverse events. Thrombocytopenia was the most frequent adverse event. In all applications significant clinical and biological improvements were shown with MARS® therapy

Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases

International audienc

Integrating an addiction team into the management of patients transplanted for alcohol-associated liver disease reduces the risk of severe relapse

International audienceBackground & Aims: Liver transplantation (LT) is a last resort treatment for patients at high risk of mortality from end-stage liver disease. Over the past years, alcohol-associated liver disease has become the most frequent indication for LT in the world. The outcomes of LT for alcohol-associated liver disease are good, but return to alcohol use is detrimental for medium-term survival because of cancer development, cardiovascular events, and recurrent alcohol-associated cirrhosis. Several strategies have been developed to prevent return to alcohol use during the pre- or post-LT period, but there are no specific recommendations. Therefore, the main objective of this study was to investigate if the integration of an addiction team in a LT unit affected the rate of severe alcohol relapse after LT. The secondary objectives were to assess the effects of addiction follow up on cardiovascular events, cancer, and overall survival.Methods: This study was a retrospective comparison between centres with or without addiction monitoring.Results: The study included 611 patients of which 79.4% were male with a mean age of 55.4 years at the time of LT, 190 were managed by an integrated addiction team. The overall alcohol relapse rate was 28.9% and the rate of severe relapse was 13.0%. Patients with addiction follow-up had significantly less frequent severe alcohol relapse than those in the control group (p = 0.0218). Addiction follow up (odds ratio = 0.19; p = 0.001) and age at LT (odds ratio = 1.23; p = 0.02) remained significantly associated with post-LT cardiovascular events.Conclusions: Our study confirms the benefits of integrating an addiction team to reduce return to alcohol use after LT.Clinical Trials registration This study is registered at ClinicalTrials.gov (NCT 04964687)