Approche de la réaction inflammatoire au cours des états infectieux graves De l'investigation à l'épidémiologie clinique

PARIS-BIUSJ-Thèses (751052125) / SudocPARIS-BIUSJ-Physique recherche (751052113) / SudocSudocFranceF

Endotoxemia and mortality prediction in ICU and other settings: underlying risk and co-detection of gram negative bacteremia are confounders.

International audienceABSTRACT: INTRODUCTION: The interdependence between endotoxemia, gram negative (GN) bacteremia and mortality has been extensively studied. Underlying patient risk and GN bacteremia types are possible confounders of the relationship. METHODS: Published studies with [greater than or equal to]10 patients in either ICU or non-ICU settings, endotoxemia detection by limulus assay, reporting mortality proportions and [greater than or equal to]1 GN bacteremia were included. Summary odds ratios (OR) for mortality were derived across all studies by meta-analysis for the following contrasts; sub-groups with either endotoxemia (group 3), GN bacteremia (group 2) or both (group 1) each versus the group with neither detected (group 4; reference group). The mortality proportion for group 4 is the proxy measure of study level risk within L'Abbe plots. RESULTS: 35 studies were found. Among 9 studies in an ICU setting, OR for mortality was borderline (OR < 2) or non-significantly increased for groups 2 (GN bacteremia alone) and 3 (endotoxemia alone) and patient group 1 (GN bacteremia and endotoxemia co-detected) each versus patient group 4 (neither endotoxemia nor GN bacteremia detected). The OR's were markedly higher for group 1 versus group 4 (OR 6.9; 95% CI, 4.4 - 11.0 when derived from non-ICU studies. The distributions of P aeruginosa and E coli bacteremias among groups 1 versus 2 are significantly unequal. CONCLUSIONS: The co-detection of GN bacteremia and endotoxemia is predictive of increased mortality risk versus the detection of neither but only in studies undertaken in a non-ICU setting. Variation in GN bacteremia species types and underlying risk are likely unrecognized confounders in the individual studies

Multiplex PCR performed of bronchoalveolar lavage fluid increases pathogen identification rate in critically ill patients with pneumonia: a pilot study

International audienceBackground: In critically ill patients with pneumonia, accurate microorganism identification allows appropriate antibiotic treatment. In patients undergoing bronchoalveolar lavage (BAL), direct examination of the fluid using Gram staining provides prompt information but pathogen identification accuracy is low. Culture of BAL fluid is actually the reference, but it is not available before 24 to 48 h. In addition, pathogen identification rate observed with direct examination and culture is decreased when antibiotic therapy has been given prior to sampling. We therefore assessed, in critically ill patients with suspected pneumonia, the performance of a multiplex PCR (MPCR) to identify pathogens in BAL fluid. This study is a prospective pilot observation. Methods: We used a MPCR detecting 20 types of microorganisms. Direct examination, culture, and MPCR were performed on BAL fluid of critically ill patients with pneumonia suspicion. The final diagnosis of infective pneumonia was retained after the medical chart was reviewed by two experts. Pathogen identification rate of direct examination, culture, and MPCR in patients with confirmed pneumonia was compared. Results: Among the 65 patients with pneumonia suspicion, the diagnosis of pneumonia was finally retained in 53 cases. Twenty nine (55%) were community-acquired pneumonia and 24 (45%) were hospital acquired. Pathogen identification rate with MPCR (66%) was greater than with culture (40%) and direct examination (23%) (p =0.01 and p <0.001, respectively). When considering only the microorganisms included in the MPCR panel, the pathogen identification rate provided by MPCR reached 82% and was still higher than with culture (35%, p <0.001) and direct examination (21%, p <0.001). Pathogen identification rate provided by MPCR was not modified in the case of previous antibiotic treatment (66% vs. 64%, NS) and was still better than with culture (23%, p <0.001). Conclusions: The results of this pilot study suggest that in critically ill patients, MPCR performed on BAL fluid could provide higher identification rate of pathogens involved in pneumonia than direct examination and culture, especially in patients having received antimicrobial treatment

Comparison of superior vena cava and femoroiliac vein pressure according to intra-abdominal pressure.

International audienceUNLABELLED: ABSTRACT: BACKGROUND: Previous studies have shown a good agreement between central venous pressure (CVP) measurements from catheters placed in superior vena cava and catheters placed in the abdominal cava/common iliac vein. However, the influence of intra-abdominal pressure on such measurements remains unknown. METHODS: We conducted a prospective, observational study in a tertiary teaching hospital. We enrolled patients who had indwelling catheters in both superior vena cava (double lumen catheter) and femoroiliac veins (dialysis catheter) and into the bladder. Pressures were measured from all the sites, CVP, femoroiliac venous pressure (FIVP), and intra-abdominal pressure. RESULTS: A total of 30 patients were enrolled (age 62 ± 14 years; SAPS II 62 (52-76)). Fifty complete sets of measurements were performed. All of the studied patients were mechanically ventilated (PEP 3 cmH20 (2-5)). We observed that the concordance between CVP and FIVP decreased when intra-abdominal pressure increased. We identified 14 mmHg as the best intra-abdominal pressure cutoff, and we found that CVP and FIVP were significantly more in agreement below this threshold than above (94% versus 50%, P = 0.002). CONCLUSIONS: We reported that intra-abdominal pressure affected agreement between CVP measurements from catheter placed in superior vena cava and catheters placed in the femoroiliac vein. Agreement was excellent when intra-abdominal pressure was below 14 mmHg

Open Access Alteration of skin perfusion in mottling area during septic shock

Background: Mottling score has been reported to be a strong predictive factor during septic shock. However, the pathophysiology of mottling remains unclear. Methods: In patients admitted in ICU for septic shock, we measured on the same area the mean skin perfusion by laser Doppler, the mottling score, and variations of both indices between T1 (6 hours after vasopressors were started) and T2 (24 hours later). Results: Fourteen patients were included, SAPS II was 56 [37–71] and SOFA score at T1 was 10 [7–12]. The mean skin surface area analyzed was 4108 ± 740 mm 2; 1184 ± 141 measurements were performed over each defined skin surface area. Skin perfusion was significantly different according to mottling score and decreased from 37 [31–42] perfusion units (PUs) for a mottling score of [0–1] to 22 [20–32] PUs for a mottling score of [2–3] and 23 [16–28] for a score of [4–5] (Kruskal-Wallis test, P = 0.05). We analyzed skin perfusion changes during resuscitation in each patient and together with mottling score variations between T1 and T2 using a Wilcoxon signed-rank test. Amon

Alteration of skin perfusion in mottling area during septic shock.

International audienceBACKGROUND: Mottling score has been reported to be a strong predictive factor during septic shock. However, the pathophysiology of mottling remains unclear. METHODS: In patients admitted in ICU for septic shock, we measured on the same area the mean skin perfusion by laser Doppler, the mottling score, and variations of both indices between T1 (6 hours after vasopressors were started) and T2 (24 hours later). RESULTS: Fourteen patients were included, SAPS II was 56 [37--71] and SOFA score at T1 was 10 [7--12]. The mean skin surface area analyzed was 4108 +/- 740 mm2; 1184 +/- 141 measurements were performed over each defined skin surface area. Skin perfusion was significantly different according to mottling score and decreased from 37 [31--42] perfusion units (PUs) for a mottling score of [0--1] to 22 [20--32] PUs for a mottling score of [2--3] and 23 [16--28] for a score of [4--5] (Kruskal-Wallis test, P = 0.05). We analyzed skin perfusion changes during resuscitation in each patient and together with mottling score variations between T1 and T2 using a Wilcoxon signed-rank test. Among the 14 patients included, mottling score increased (worsened) in 5 patients, decreased (improved) in 5 patients, and remained stable in 4 patients. Baseline skin perfusion at T1 was arbitrarily scored 100%. Mean skin perfusion significantly decreased in all the patients whose mottling score worsened from 100% baseline to 63.2 +/- 10.7% (P = 0.001), mean skin perfusion significantly increased in all patients whose mottling score improved from 100% baseline to 172.6 +/- 46.8% (P = 0.001), and remained stable in patients whose mottling score did not change (100.5 +/- 6.8%, P = 0.95). CONCLUSIONS: We have shown that mottling score variations and skin perfusion changes during septic shock resuscitation were correlated, providing additional evidence that mottling reflects skin hypoperfusion