Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination

AbstractObjectivesPancreaticoduodenectomy (PD) is associated with high morbidity, in part as a result of infectious complications increased by preoperative bile contamination. The aim of the present study was to assess the effect on the incidence of infectious complications of short‐term antimicrobial therapy (AMT) in high‐risk patients.MethodsPatients with a high risk for positive intraoperative bile culture (i.e. those with ampulloma or pancreatic adenocarcinoma with preoperative endoscopic procedures) (high‐risk group, n = 99) were compared with low‐risk patients (i.e. those with pancreatic adenocarcinoma without preoperative endoscopic procedures) (low‐risk group, n = 76). The high‐risk group received a 5‐day course of perioperative AMT secondarily adapted to the bile antibiogram. The low‐risk group received only the usual antimicrobial prophylaxis.ResultsPositive bile cultures were significantly more frequent in high‐risk patients (81% versus 12%; P < 0.001). The overall rate of infectious complications was lower in the high‐risk group (29% versus 46%; P = 0.018). The statistically significant decrease in the rate of infectious complications reflected reduced rates of urinary tract infections, pulmonary infections and septicaemia. Rates of wound infection (3% versus 5%; P = 0.639) and intra‐abdominal abscess (7% versus 7%; P = 0.886) were similar in the high‐ and low‐risk groups, as was the need for curative AMT.ConclusionsThis exploratory study suggests that a postoperative short course of AMT in patients at high risk for biliary contamination reduces the overall rate of infectious complications after PD. The adaptation of perioperative antimicrobial policy to the patient's risk for bile contamination seems promising and should be further evaluated

PathFinder 2015

担当教員:姉川雄大平成27年度(2015)教養展開科目(国際コア関連),授業コード:Ｇ15N1060

Liver function abnormalities, clinical profile, and outcome in acute decompensated heart failure

AIMS: The aim of this study was to assess the prevalence of abnormal liver function tests (LFTs) and the associated clinical profile and outcome(s) in acute decompensated heart failure (ADHF) patients. Alteration in LFTs is a recognized feature of ADHF, but prevalence and outcomes data from a broad contemporary cohort of ADHF are scarce and the mechanism(s) of ADHF-induced cholestasis is unknown. METHODS AND RESULTS: We conducted a post hoc analysis of SURVIVE, a large clinical trial including ADHF patients treated with levosimendan or dobutamine. All LFTs were available in 1134 patients at baseline. Abnormal LFTs were seen in 46% of ADHF patients: isolated abnormal alkaline phosphatase (AP) was noted in 11%, isolated abnormal transaminases in 26%, and a combination of abnormal AP and transaminases in 9%. Abnormal AP was associated with marked signs of systemic congestion and elevated right-sided filling pressure. Abnormal AP had no relationship with 31-day mortality but was associated with worse 180-day mortality (23.5 vs. 34.9%, P = 0.001 vs. patients with normal AP). Abnormal transaminases were associated with clinical signs of hypoperfusion and with greater 31-day and 180-day mortality compared with normal transaminase profiles (17.6 vs. 8.4% and 31.6 vs. 22.4%, respectively; both P < 0.001). There was no additive value of abnormal AP plus abnormal transaminase on a long-term outcome. CONCLUSION: Abnormal LFTs were present in about a half of patients presenting with ADHF treated with inotropes. Abnormal AP and abnormal transaminases were associated with specific clinical, biological, and prognostic features, including a short-term overmortality with increased transaminases but not with biological signs of cholestasis, in ADHF patient

Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients – A prospective multicenter observational study (iSOFA study)

Background & aims: To develop a five grade score (0–4 points) for the assessment of gastrointestinal (GI) dysfunction in adult critically ill patients. Methods: This prospective multicenter observational study enrolled consecutive adult patients admitted to 11 intensive care units in nine countries. At all sites, daily clinical data with emphasis on GI clinical symptoms were collected and intra-abdominal pressure measured. In five out of 11 sites, the biomarkers citrulline and intestinal fatty acid-binding protein (I-FABP) were measured additionally. Cox models with time-dependent scores were used to analyze associations with 28- and 90-day mortality. The models were estimated with stratification for study center. Results: We included 540 patients (224 with biomarker measurements) with median age of 65 years (range 18–94), the Simplified Acute Physiology Score II score of 38 (interquartile range 26–53) points, and Sequential Organ Failure Assessment (SOFA) score of 6 (interquartile range 3–9) points at admission. Median ICU length of stay was 3 (interquartile range 1–6) days and 90-day mortality 18.9%. A new five grade Gastrointestinal Dysfunction Score (GIDS) was developed based on the rationale of the previously developed Acute GI Injury (AGI) grading. Citrulline and I-FABP did not prove their potential for scoring of GI dysfunction in critically ill. GIDS was independently associated with 28- and 90-day mortality when added to SOFA total score (HR 1.40; 95%CI 1.07–1.84 and HR 1.40; 95%CI 1.02–1.79, respectively) or to a model containing all SOFA subscores (HR 1.48; 95%CI 1.13–1.92 and HR 1.47; 95%CI 1.15–1.87, respectively), improving predictive power of SOFA score in all analyses. Conclusions: The newly developed GIDS is additive to SOFA score in prediction of 28- and 90-day mortality. The clinical usefulness of this score should be validated prospectively. Trial registration: NCT02613000, retrospectively registered 24 November 2015.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate &gt;500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access

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/)

Incidence et facteurs de risque de lésions non diagnostiquées lors de la lecture initiale des scanners corps entier des patients polytraumatisés

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

Etude des facteurs pronostiques de morbi-mortalité en chirurgie hépato-biliaire et transplantation hépatique

Les complications postopératoires après chirurgie hépatique et transplantation hépatique (TH) génèrent une mortalité importante. Le diagnostic précoce de ces complications est la pierre angulaire d une amélioration de la prise en charge et de la survie. Les facteurs pronostiques de morbi-mortalité après chirurgie hépatique et TH ont été examinés. L insuffisance hépatique représente une complication redoutable après hépatectomie. La survenue d une insuffisance hépatique associant une bilirubine supérieure à 50 mol/l et d un TP inférieur à 50 % à J3 et à J5 après résection hépatique est un facteur pronostique indépendant de mortalité en réanimation. La mortalité précoce après TH est de l ordre de 10% à 3 mois, liée à la survenue de défaillances d organes initiée par des événements peropératoires et/ou postopératoires. En peropératoire, l impact et les facteurs prédictifs de survenue d un syndrome de reperfusion lors de la revascularisation du greffon hépatique ont été étudiés. La durée d ischémie froide et l absence d anastomose portocave sont des facteurs prédictifs indépendants d un syndrome de reperfusion. Ce syndrome est associé à une fréquence accrue d insuffisance rénale et une surmortalité précoce en réanimation. En postopératoire, les infections bactériennes constituent la première cause de mortalité précoce après TH et restent de diagnostic difficile. La comparaison des profils protéiques plasmatiques obtenus en technologie SELDI-TOF a permis d identifier des profils spécifiquement exprimés en cas d infection après TH. L ensemble des éléments étudiés dans cette thèse constitue des cibles potentielles d amélioration de la morbi-mortalité après chirurgie hépatique.PARIS-BIUSJ-Physique recherche (751052113) / SudocSudocFranceF

Evaluation d une stratégie d immunonutrition orale préopératoire en transplantation hépatique (résultats d une étude pilote)

La cirrhose se caractérise par une dénutrition quasi constante, associée à une majoration de la morbi-mortalité transplantation hépatique (TH). Il est recommandé de prendre en charge cette dénutrition préopératoire. L objectif de ce travail était d évaluer les effets d une immunonutrition pré-opératoire sur les paramètres nutritionnels pré TH immédiats et sur la morbi-mortalité post-opératoire.Cohorte prospective monocentrique non randomisée de patients cirrhotiques en attente de TH. Le statut nutritionnel était évalué grâce à la mesure de la force de préhension de la main avant supplémentation puis en pré TH immédiat. Les données de morbi-mortalité postopératoire étaient recueillies grâce à une base de données prospective.64 patients ont été inclus. Leur force de préhension médiane avant supplémentation était significativement inférieure à la valeur attendue (33.1kg [26.2 ; 40.4] vs 45kg [40 ; 47] respectivement, p=0,003). 13 patients ont été transplantés à ce jour. Les valeurs pré TH n étaient pas significativement différentes des valeurs initiales. L analyse préliminaire suggérait une possible réduction de la morbidité post-opératoire notamment infectieuse, par rapport à la cohorte antérieure de patients transplantés sans supplémentation.Malgré un effectif limité de patients ayant reçu une immunonutrition préopératoire et transplantés, les résultats préliminaires sont encourageants et semblent cohérents avec les effets déjà démontrés de l immunonutrition dans d autres types de chirurgies abdominales. Ceci souligne l importance d une stratégie de prise en charge nutritionnelle des patients cirrhotiques en attente de TH.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF