Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

What are the ethical aspects surrounding intensive care unit admission in patients with cancer?

International audienceImprovements in living conditions and increasing life expectancy have combined to result in ever older patients being admitted to hospital. In parallel, the increasing incidence of cancer, along with the improved efficacy of anti-cancer therapies has led to greater needs for intensive care among cancer patients. The objectives underpinning the management of cancer patients in the intensive care unit (ICU) are to achieve a return to a clinical status that would allow the patient to be either, transferred back to the original unit, or discharged from the hospital with an acceptable quality of life, and where warranted, pursuit of cancer therapy. The relevance of ICU admission should be assessed systematically for patients with active cancer. The decision needs to be made taking into account the expected benefit for the patient, the life-support therapies that are possible with discussion about a care project, and also considering the future quality of life and the short and long-term prognosis. Anticipating the question of potential ICU admission should help protect the patient against both inappropriate refusal of intensive care, and inappropriate admission to the ICU that might only lead to unreasonable therapeutic obstinacy. The intensive care physician has a major role to play in helping the cancer patient to develop an appropriate and flexible healthcare project. Anticipating the question of ICU admission in advance, as well as a close alliance between the oncologist and the intensive care physician are the two keys to the success of a healthcare project focused on the patient

The concept of a surrogate is ill adapted to intensive care: Criteria for recognizing a reference person

IF 2.445International audiencePurpose: In the intensive care unit (ICU), caregivers may find it difficult to identify a suitable person in the patient's entourage to serve as a reference when there is no official surrogate.Methods: We developed a 12-item questionnaire to identify factors potentially important for caregivers when identifying a reference person. Each criterion was evaluated as regards its importance for the role of reference. Responses were on a scale of 0 (not important) to 10 (extremely important). We recorded respondent's age, job title, and number of years' ICU experience. The questionnaire was distributed to all health care professionals in 2 French ICUs.Results: Among 144 staff, 128 were contacted; 99 completed the questionnaire (77% response rate; 20 physicians [ 11 residents], 51 nurses, 28 nurse's aides). Items classed as most important attributes for a reference person were knowledge of patient's wishes and values, emotional attachment, adequate understanding of the clinical history, and designation as a surrogate before admission. There were no significant differences according to respondent's age, job title, or experience.Conclusion: Caregivers identify a reference person based on criteria such as knowledge of the patient's wishes, emotional bond with the patient, an adequate understanding of the clinical history, and designation as surrogate before admission. (C) 2015 Elsevier Inc. All rights reserved

Severe serotonin syndrome caused by an interaction between an antidepressant and a cough syrup

International audienc

Additional file 1 of ROX index performance to predict high-flow nasal oxygen outcome in Covid-19 related hypoxemic acute respiratory failure

Additional file 1: Figure S1. Receiver operating characteristic curves for HFNO failure within 28 days at different times after HFNO initiation. HFNO: high-flow nasal oxygen therapy; ROC: receiver operating characteristic; H0: ROC curve at the time of HFNO initiation; H12:12 hours after HFNO initiation; H18: 18 hours after HFNO initiation; H24:24 hours after HFNO initiation. Figure S2. Rox index performance to predict the risk of HFNO failure at different times after HFNO initiation. HFNO: high-flow nasal oxygen therapy; red line gives proportion of patients in the HFNO failure group with a ROX index ≤ a chosen cut-off value; black line gives proportion of patients in the HFNO success group with a ROX index ≤ a chosen cut-off value. For example: at H6, using a Rox index of ≤8.50 as cut-off would identify 90% of patients with HFNO failure after H6, whereas this cut-off would identify only 38% of patients with HFNO success after H6, avoiding intubation. Figure S3. Incidence of HFNO failure within 7 days after HFNO initiation. HFNO: high-flow nasal oxygen therapy. Table S4. Conditions of intubation and clinical respiratory parameters in all intubated patients and according to hemodynamic status. HFNO: high-flow nasal oxygen therapy; FiO2: fraction of inspired oxygen; SpO2: pulse oxygen saturation; RR: respiratory rate; values are expressed as n (%) or median (Q1-Q3). Table S5. Rox index at H0, HFNO outcome and duration according to each ICU center. HFNO: high-flow nasal oxygen therapy; ICU: intensive care unit; values are expressed as n (%) or median (Q1-Q3); *= logistic regression unless stated otherwise; **= Kruskall-Wallis’s test

Relationship between obesity and ventilator-associated pneumonia: a post-hoc analysis of the NUTRIREA2 trial.

International audiencePatients with obesity are at higher risk for community-acquired and nosocomial infections. However, no study has specifically evaluated the relationship between obesity and ventilator-associated pneumonia (VAP)

Impact of nutrition route on microaspiration in critically ill patients with shock: a planned ancillary study of the NUTRIREA-2 trial

International audienceBACKGROUND: Microaspiration of gastric and oropharyngeal secretions is the main mechanism of entry of bacteria into the lower respiratory tract in intubated critically ill patients. The aim of this study is to determine the impact of enteral nutrition, as compared with parenteral nutrition, on abundant microaspiration of gastric contents and oropharyngeal secretions.METHODS: Planned ancillary study of the randomized controlled multicenter NUTRIREA2 trial. Patients with shock receiving invasive mechanical ventilation were randomized to receive early enteral or parenteral nutrition. All tracheal aspirates were collected during the 48 h following randomization. Abundant microaspiration of gastric contents and oropharyngeal secretions was defined as the presence of significant levels of pepsin (> 200 ng/ml) and salivary amylase (> 1685 UI/ml) in > 30% of tracheal aspirates.RESULTS: A total of 151 patients were included (78 and 73 patients in enteral and parenteral nutrition groups, respectively), and 1074 tracheal aspirates were quantitatively analyzed for pepsin and amylase. Although vomiting rate was significantly higher (31% vs 15%, p = 0.016), constipation rate was significantly lower (6% vs 21%, p = 0.010) in patients with enteral than in patients with parenteral nutrition. No significant difference was found regarding other patient characteristics. The percentage of patients with abundant microaspiration of gastric contents was significantly lower in enteral than in parenteral nutrition groups (14% vs 36%, p = 0.004; unadjusted OR 0.80 (95% CI 0.69, 0.93), adjusted OR 0.79 (0.76, 0.94)). The percentage of patients with abundant microaspiration of oropharyngeal secretions was significantly higher in enteral than in parenteral nutrition groups (74% vs 54%, p = 0.026; unadjusted OR 1.21 (95% CI 1.03, 1.44), adjusted OR 1.23 (1.01, 1.48)). No significant difference was found in percentage of patients with ventilator-associated pneumonia between enteral (8%) and parenteral (10%) nutrition groups (HR 0.78 (0.26, 2.28)).CONCLUSIONS: Our results suggest that enteral and parenteral nutrition are associated with high rates of microaspiration, although oropharyngeal microaspiration was more common with enteral nutrition and gastric microaspiration was more common with parenteral nutrition

Émotions et discours

Défini dans la Rhétorique et dans la Poétique d’Aristote comme un langage-action, le pathos est l’une des techniques d’argumentation destinée à produire la persuasion, cela en émouvant les récepteurs. Les critiques de cette raison pratique n’ont cessé de dénoncer sa dimension manipulatrice et démagogique, constatant son écart avec le raisonnement formel centré sur la vérité objective. Cependant, l’analyse des émotions dans la langue permet de reconnaître la problématique essentielle de la culture, celle qui consiste à favoriser ou, au contraire, à nier la logique singulière d’une identité et d’une différence. Les études présentées dans ce livre proposent de soulever cette réflexion qui paraît urgente, compte tenu de la montée en puissance des nouveaux discours communautaristes, négationnistes et racistes. Empruntant aux passions communes, ces discours cherchent à réduire la pluralité des valeurs culturelles nécessaires à la vie en société. Fruit de discussions passionnées, cet ouvrage intéressera celles et ceux qui pensent que les émotions participent au dialogue entre individus et que l’étude des passions dans la langue favorise une meilleure compréhension des pratiques culturelles contemporaines