Acute Heart Failure Management

Acute heart failure (AHF) is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. However, there are few evidence-based treatment methods. Interestingly, despite relatively similar ways of management of AHF throughout the globe, mid-term outcome in East Asia, including South Korea is more favorable than in Europe. Yet, most of the treatment methods are symptomatic. The cornerstone of AHF management is identifying precipitating factors and specific phenotype. Multidisciplinary approach is important in AHF, which can be caused or aggravated by both cardiac and non-cardiac causes. The main pathophysiological mechanism in AHF is congestion, both systemic and inside the organs (lung, kidney, or liver). Cardiac output is often preserved in AHF except in a few cases of advanced heart failure. This paper provides guidance on AHF management in a time-based approach. Treatment strategies, criteria for triage, admission to hospital and discharge are described.Peer reviewe

Empiric antimicrobial therapy for ventilator-associated pneumonia after brain injury

International audienceIssues regarding recommendations on empiric antimicrobial therapy for ventilator-associated pneumonia (VAP) have emerged in specific populations.To develop and validate a score to guide empiric therapy in brain-injured patients with VAP, we prospectively followed a cohort of 379 brain-injured patients in five intensive care units. The score was externally validated in an independent cohort of 252 brain-injured patients and its extrapolation was tested in 221 burn patients.The multivariate analysis for predicting resistance (incidence 16.4%) showed two independent factors: preceding antimicrobial therapy ≥48 h (p\textless0.001) and VAP onset ≥10 days (p\textless0.001); the area under the receiver operating characteristic curve (AUC) was 0.822 (95% CI 0.770-0.883) in the learning cohort and 0.805 (95% CI 0.732-0.877) in the validation cohort. The score built from the factors selected in multivariate analysis predicted resistance with a sensitivity of 83%, a specificity of 71%, a positive predictive value of 37% and a negative predictive value of 96% in the validation cohort. The AUC of the multivariate analysis was poor in burn patients (0.671, 95% CI 0.596-0.751).Limited-spectrum empirical antimicrobial therapy has low risk of failure in brain-injured patients presenting with VAP before day 10 and when prior antimicrobial therapy lasts \textless48 

Readmission following both cardiac and non-cardiac acute dyspnoea is associated with a striking risk of death

Readmission and mortality are the most common and often combined endpoints in acute heart failure (AHF) trials, but an association between these two outcomes is poorly investigated. The aim of this study was to determine whether unplanned readmission is associated with a greater subsequent risk of death in patients with acute dyspnoea due to cardiac and non-cardiac causes.; Derivation cohort (1371 patients from the LEDA study) and validation cohort (1986 patients from the BASEL V study) included acute dyspnoea patients admitted to the emergency department. Cox regression analysis was used to determine the association of 6 month readmission and the risk of 1 year all-cause mortality in AHF and non-AHF patients and those readmitted due to cardiovascular and non-cardiovascular causes. In the derivation cohort, 666 (49%) of patients were readmitted at 6 months and 282 (21%) died within 1 year. Six month readmission was associated with an increased 1 year mortality risk in both the derivation cohort [adjusted hazard ratio (aHR) 3.0 (95% confidence interval, CI 2.2-4.0), P < 0.001] and the validation cohort (aHR 1.8, 95% CI 1.4-2.2, P < 0.001). The significant association was similarly observed in AHF (aHR 3.2, 95% CI 2.1-4.9, P < 0.001) and other causes of acute dyspnoea (aHR 2.9, 95% CI 1.9-4.5, P < 0.001), and it did not depend on the aetiology [aHR 2.2, 95% CI 1.6-3.1 for cardiovascular readmissions; aHR 4.1, 95% CI 2.9-5.7 for non-cardiovascular readmissions (P < 0.001 for both)] or timing of readmission. CONCLUSION​S: Our study demonstrated a long-lasting detrimental association between readmission and death in AHF and non-AHF patients with acute dyspnoea. These patients should be considered 'vulnerable patients' that require personalized follow-up for an extended period

Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery

ImportanceBefore surgery, the best strategy for managing patients who are taking renin-angiotensin system inhibitors (RASIs) (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) is unknown. The lack of evidence leads to conflicting guidelines.ObjectiveTo evaluate whether a continuation strategy vs a discontinuation strategy of RASIs before major noncardiac surgery results in decreased complications at 28 days after surgery.Design, setting, and participantsRandomized clinical trial that included patients who were being treated with a RASI for at least 3 months and were scheduled to undergo a major noncardiac surgery between January 2018 and April 2023 at 40 hospitals in France.InterventionPatients were randomized to continue use of RASIs (n = 1107) until the day of surgery or to discontinue use of RASIs 48 hours prior to surgery (ie, they would take the last dose 3 days before surgery) (n = 1115).Main outcomes and measuresThe primary outcome was a composite of all-cause mortality and major postoperative complications within 28 days after surgery. The key secondary outcomes were episodes of hypotension during surgery, acute kidney injury, postoperative organ failure, and length of stay in the hospital and intensive care unit during the 28 days after surgery.ResultsOf the 2222 patients (mean age, 67 years [SD, 10 years]; 65% were male), 46% were being treated with angiotensin-converting enzyme inhibitors at baseline and 54% were being treated with angiotensin receptor blockers. The rate of all-cause mortality and major postoperative complications was 22% (245 of 1115 patients) in the RASI discontinuation group and 22% (247 of 1107 patients) in the RASI continuation group (risk ratio, 1.02 [95% CI, 0.87-1.19]; P = .85). Episodes of hypotension during surgery occurred in 41% of the patients in the RASI discontinuation group and in 54% of the patients in the RASI continuation group (risk ratio, 1.31 [95% CI, 1.19-1.44]). There were no other differences in the trial outcomes.Conclusions and relevanceAmong patients who underwent major noncardiac surgery, a continuation strategy of RASIs before surgery was not associated with a higher rate of postoperative complications than a discontinuation strategy.Trial registrationClinicalTrials.gov Identifier: NCT03374449

Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial

Background: There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. Methods: In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24&nbsp;h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). Results: We included 1217 patients (mean age 51.2&nbsp;years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9&nbsp;J/min [IQR 9.2-15.1], 13&nbsp;J/min [IQR 10-17], and 14&nbsp;J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9&nbsp;J/min, aRR at 17&nbsp;J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). Conclusions: Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation

Left ventricular longitudinal systolic function evaluation with Speckle- Tracking echocardiography in brain-injured patients undergoing invasive mechanical ventilation

L’analyse de la fonction systolique longitudinale par speckletracking permet d’analyser les mouvements de déformations du myocarde ainsi que la fonction systolique longitudinale ventriculaire gauche. Le Strain Longitudinal Global (SLG) est le paramètre le plus étudié en cardiologie et s’intéresse aux déformations du grand axe du ventricule gauche. Il n’existe pas de données sur le SLG chez les patients atteints d’une pathologie cérébrale aiguë placés sous ventilation mécanique, alors que les cardiopathies de stress ont été largement décrites dans ce contexte. Nous avons évalué le SLG chez des patients atteints d’hémorragie sous-arachnoïdienne par rupture d’anévrysme. Il existait plus de 30% de cardiopathies de stress évaluée par le SLG, alors que la fraction d’éjection ventriculaire gauche était normale. Chez les patients traumatisés crâniens, nous avons observé une absence de cardiopathies de stress, avec un SLG conservé. Néanmoins nous ne pouvons exclure que les anomalies constatées sont liées aux variations des conditions de charge secondaires à la ventilation mécanique. Nous avons testé l’effet de la ventilation mécanique invasive après anesthésie générale au bloc opératoire sur le SLG, ainsi que les effets du lever de jambe passif. Au décours de l’anesthésie générale, il existe une altération modeste mais significative du SLG. Après une épreuve de lever de jambe passif, l’altération du SLG est persistante. En conclusion, les altérations du SLG témoignant d’une cardiopathie de stress, sont spécifiques en neuroréanimation, mais l’analyse du SLG doit prendre en compte les variations rapides de conditions de charge..Speckle-tracking echography allows the analysis of left ventricular strain movements and longitudinal systolic function. Global Longitudinal Strain (GLS) is the most studied parameter in cardiology and provides data regarding strain movements of the left ventricle in the long axis. There are no data regarding SLG in neurocritical care patients undergoing invasive mechanical ventilation, although stress cardiomyopathy has been numerously described in this context. We have studied GLS in patients with aneurysmal subarachnoid haemorrhage. We identified over 30% of stress cardiomyopathy with GLS along with preserved left ventricular ejection fraction. In patients with traumatic brain injury, GLS was preserved implying the absence of stress cardiomyopathy. However, we could not rule out that GLS alterations were the consequences of the variations in the loading conditions of the left ventricle, because of mechanical ventilation. We tested these effects in patients undergoing invasive mechanical ventilation with general anaesthesia in the operating room. We also tested the effects of passive leg raising. After general anaesthesia, we witnessed a moderate but significant GLS impairment. After a passive leg raising test, GLS impairment was still present. In definite, GLS’s modifications are specific of the neurocritical care setting and imply the existence of stress cardiomyopathy, but GLS analysis must consider rapid modifications of the loading conditions

Analyse microbiologique des péritonites secondaires de l'adulte au Centre Hospitalo-Universitaire de Nantes

Les péritonites sont des infections graves, mettant en jeu le pronostic vital et dont le traitement est médico-chirurgical. L'antibiothérapie doit être débutée dès la chirurgie et doit cibler les germes retrouvés dans le péritoine. Notre étude rétrospective en 2005 et 2006 a mis en évidence une majorité d'Escherichia coli dans les péritonites communautaires et les péritonites nosocomiales non postopératoires, dont la sensibilité à l amoxicilline était moyenne mais la sensibilité à l amoxicilline-acide clavulanique était conservée. Cette sensibilité à l amoxicilline-acide clavulanique est différente de celle constatée sur les souches d Escherichia coli retrouvés dans les infections urinaires. Il existait une proportion importante de germes anaérobies avec une sensibilité conservée à l amoxicilline-acide clavulanique et moyenne pour la clindamycine. L amoxicilline-acide clavulanique pourrait être proposée à Nantes, comme antibiothérapie probabiliste pour les péritonites communautaires et nosocomiales non post-opératoires. Les Escherichia coli retrouvés dans les péritonites post-opératoires avaient une sensibilité diminuée aux bêta-lactamines. Les bactéries multi-résistantes étaient plus souvent retrouvées, conformément aux séries de la littérature. Chez ces patients, une antibiothérapie à large spectre est impérative.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

The Black esophagus (à propos d'un cas en réanimation chirurgicale au CHU de Nantes)

L'œsophage noir ou nécrose œsophagienne aiguë (= Black esophagus) est une complication digestive rare, peu décrite dans la littérature médicale, se manifestant principalement par une hémorragie digestive haute. La première description in vivo remonte à 1990 par Goldenberg [1]. Le diagnostic est facilement réalisé par une endoscopie digestive qui montre une nécrose œsophagienne à limite nette [2,3], excluant une cause caustique. L'étiologie demeure mal connue et semble multifactorielle. La mortalité globale est élevée, proche de 32%, en rapport principalement avec un terrain fragile [4,7-13]. Le traitement actuel reste médical avec une évolution possible vers une guérison complète. A partir d'un cas typique, une revue exhaustive de la littérature a été réalisée pour mieux comprendre les différentes étiologies, afin de pouvoir mettre en place une stratégie thérapeutique adaptée.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF