Severe respiratory distress secondary to pharyngeal perforation during endoscopic gastrostomy tube removal: a clinical case report

We present the case of a 60-year-old patient with advanced chronic obstructive pulmonary disease (COPD), who presented for planned endoscopic removal of her gastrostomy feeding tube, which was inserted for nutritional status optimization prior to lung transplantation. The procedure was complicated by accidental blockage of the device at the pharyngeal level, causing a transmural laceration. Rapid respiratory distress developed with subcutaneous emphysema that led to the intubation of the patient. A new endoscopic retrieval was attempted but failed, and the patient was sent to the operating room after a cervical and thoracic CT scan that showed the blocked piece in the cervical wall, in addition to diffuse subcutaneous emphysema, a large pneumomediastinum, and a left pneumothorax. The surgery consisted of a left cervicotomy, a pharyngeal incision, and retrieval of the trapped parts. The patient was sent to the intensive care unit (ICU) where she could be weaned and extubated 1 week later

L’activation des polynucléaires neutrophiles au cours du choc septique

This PhD thesis focused on the activation of polymorphonuclear granulocytes (PMNs) during septic shock. After an introduction including an overview on pathophysiology of septic shock, disseminated intravascular coagulation (DIC) and PMNs, original experimental and clinical data are reported. In a prospective study, we enrolled 100 patients and showed that neutrophils’ activation measured by neutrophil fluorescence using flow cytometry could represent an original biomarker of septic shock-induced DIC. Furthermore, we highlighted a mechanism of neutrophil’s activation: NETosis, through assessment of indirect serum’s markers associated specifically to DIC during septic shock. In order to confirm the relevance of this result, we reported a direct visualization of circulating NETs in blood of DIC-patients using immunofluorescence. Finally, we performed a proteomic study and identified some proteins involved in neutrophils’ activation during septic shock-induced DIC. Thus, PMN could represent an important actor of immunothrombosis’ deregulation during DIC, and could be considered as a potential therapeutic target.Ce travail visait à étudier l’activation des polynucléaires neutrophiles (PNNs) au cours du choc septique. Après une introduction sur la physiopathologie du choc septique, de la coagulation intravasculaire disséminée (CIVD) et des PNNs, nous rapportons différents résultats expérimentaux et cliniques. Dans une étude prospective sur 100 patients, nous avons montré que l’activation des PNNs, mesurée par leur fluorescence en cytométrie en flux pourrait représenter un marqueur diagnostique original de la CIVD du choc septique. Ensuite, nous avons mis en évidence un des mécanismes de l’activation des PNNs, la NETose, à l’aide de marqueurs sériques. Afin de confirmer la relevance de ce phénomène, nous avons visualisé les NETs spécifiquement dans le sang de patients en choc septique avec CIVD en immunofluorescence. Enfin, nous avons identifié des protéines associées à l’activation du PNN dans la CIVD du choc septique par une étude protéomique, afin d’en envisager les mécanismes. Le PNN pourrait ainsi être un acteur incontournable de la dérégulation de l’immunothrombose au cours de la CIVD, et être envisagé comme cible thérapeutique

Neutrophils’ activation during septic shock

Ce travail visait à étudier l’activation des polynucléaires neutrophiles (PNNs) au cours du choc septique. Après une introduction sur la physiopathologie du choc septique, de la coagulation intravasculaire disséminée (CIVD) et des PNNs, nous rapportons différents résultats expérimentaux et cliniques. Dans une étude prospective sur 100 patients, nous avons montré que l’activation des PNNs, mesurée par leur fluorescence en cytométrie en flux pourrait représenter un marqueur diagnostique original de la CIVD du choc septique. Ensuite, nous avons mis en évidence un des mécanismes de l’activation des PNNs, la NETose, à l’aide de marqueurs sériques. Afin de confirmer la relevance de ce phénomène, nous avons visualisé les NETs spécifiquement dans le sang de patients en choc septique avec CIVD en immunofluorescence. Enfin, nous avons identifié des protéines associées à l’activation du PNN dans la CIVD du choc septique par une étude protéomique, afin d’en envisager les mécanismes. Le PNN pourrait ainsi être un acteur incontournable de la dérégulation de l’immunothrombose au cours de la CIVD, et être envisagé comme cible thérapeutique.This PhD thesis focused on the activation of polymorphonuclear granulocytes (PMNs) during septic shock. After an introduction including an overview on pathophysiology of septic shock, disseminated intravascular coagulation (DIC) and PMNs, original experimental and clinical data are reported. In a prospective study, we enrolled 100 patients and showed that neutrophils’ activation measured by neutrophil fluorescence using flow cytometry could represent an original biomarker of septic shock-induced DIC. Furthermore, we highlighted a mechanism of neutrophil’s activation: NETosis, through assessment of indirect serum’s markers associated specifically to DIC during septic shock. In order to confirm the relevance of this result, we reported a direct visualization of circulating NETs in blood of DIC-patients using immunofluorescence. Finally, we performed a proteomic study and identified some proteins involved in neutrophils’ activation during septic shock-induced DIC. Thus, PMN could represent an important actor of immunothrombosis’ deregulation during DIC, and could be considered as a potential therapeutic target

Neutrophils’ activation during septic shock

Ce travail visait à étudier l’activation des polynucléaires neutrophiles (PNNs) au cours du choc septique. Après une introduction sur la physiopathologie du choc septique, de la coagulation intravasculaire disséminée (CIVD) et des PNNs, nous rapportons différents résultats expérimentaux et cliniques. Dans une étude prospective sur 100 patients, nous avons montré que l’activation des PNNs, mesurée par leur fluorescence en cytométrie en flux pourrait représenter un marqueur diagnostique original de la CIVD du choc septique. Ensuite, nous avons mis en évidence un des mécanismes de l’activation des PNNs, la NETose, à l’aide de marqueurs sériques. Afin de confirmer la relevance de ce phénomène, nous avons visualisé les NETs spécifiquement dans le sang de patients en choc septique avec CIVD en immunofluorescence. Enfin, nous avons identifié des protéines associées à l’activation du PNN dans la CIVD du choc septique par une étude protéomique, afin d’en envisager les mécanismes. Le PNN pourrait ainsi être un acteur incontournable de la dérégulation de l’immunothrombose au cours de la CIVD, et être envisagé comme cible thérapeutique.This PhD thesis focused on the activation of polymorphonuclear granulocytes (PMNs) during septic shock. After an introduction including an overview on pathophysiology of septic shock, disseminated intravascular coagulation (DIC) and PMNs, original experimental and clinical data are reported. In a prospective study, we enrolled 100 patients and showed that neutrophils’ activation measured by neutrophil fluorescence using flow cytometry could represent an original biomarker of septic shock-induced DIC. Furthermore, we highlighted a mechanism of neutrophil’s activation: NETosis, through assessment of indirect serum’s markers associated specifically to DIC during septic shock. In order to confirm the relevance of this result, we reported a direct visualization of circulating NETs in blood of DIC-patients using immunofluorescence. Finally, we performed a proteomic study and identified some proteins involved in neutrophils’ activation during septic shock-induced DIC. Thus, PMN could represent an important actor of immunothrombosis’ deregulation during DIC, and could be considered as a potential therapeutic target

Direct Visualization of Circulating Neutrophil Extracellular Traps Using Cell Fluorescence during Human Septic Shock-Induced Disseminated Intravascular Coagulation

International audienceSeptic shock is the most severe form of infection, defined as a subset of sepsis in which circulatory, cellular and metabolic abnormalities are profound and responsible for multiple organ failure and a high mortality-rate. Septic shock is characterized by a broad coagulation activation that can lead to uncontrolled thrombin and fibrin generation, which may evolve to disseminated intravascular coagulation (DIC). DIC increases the risk of death, thus representing a therapeutic target of interest. However, the pathophysiological mechanisms of DIC are not fully understood. Polymorphonuclear neutrophils (PMNs) have recently been identified as potential players of the response to infection by releasing their content, including DNA, histones and granules enzymes. These structures, called neutrophils extracellular traps (NETs), form a large net-like structure in which pathogens get trapped. NETs capture invading pathogens, but also represent a pro-coagulant surface at the interface between immunity and thrombosis. During septic shock-induced DIC, neutrophil activation may result in excessive NET formation. In this study, we originally report the presence of circulating NETs in human blood during septic shock-induced DIC using a simple and robust method. Blood samples were obtained from healthy human volunteers (n=3), patients with septic shock without DIC (n=3) and with DIC (n=3). PMNs were immediately purified immediately after sampling using negative immune-magnetic sorting method. 5x104 purified PMNs were subsequently spotted on microscope slides using cytocentrifugation at 35g for 5 minutes, thus preserving cell integrity and morphology. Positive controls for NET formation were obtained using PMNs isolated from healthy volunteers that were stimulated in-vitro with 4 μM ionomycin. PMNs were stained with mouse anti-human FITC anti-myeloperoxidase (MPO) antibody and the blue-fluorescent DAPI nucleic acid stain. NETs were identified as elongated extracellular DAPI stained DNA fibers associated to MPO detected by immunofluorescence microscopy. The degree of NETs formation was blindly quantified into 5 categories according to the proportion of neutrophils forming NETs per microscopic field: absence (0% of neutrophils forming NETs), scarce (1-25%), moderate (26% to 50%), high (50% to 75%) or very high degree of NETS formation (76% to 100%). PMNs from healthy donors stimulated by ionomycin released NETs, evidenced as double-stained DAPI-positive chromatin structures decorated with MPO in the extracellular space using fluorescence microscopy. NET structures similar to those observed after ionomycin stimulation were unambiguously visualized in PMNs from septic shock patients with DIC, but neither in PMNs from septic shock patients without DIC, nor in unstimulated PMNs from healthy donors. DIC patients were stratified into "high" or "very high" degree of NETs formation groups (>75 % of PMNs displaying DNA release), not different from ionomycin-stimulated PMNs (50 to 75%). Conversely, PMNs from patients devoid of DIC as well as unstimulated normal PMNs from healthy volunteers were stratified into "scarce" or "absence" of PMNs forming NET categories. Blind review of May-Giemsa-Grunwald (MGG) stained slides showed the correlation of the detection of NETs with nuclear decondensation and vacuolation of the cytoplasm of PMNs, features that are associated with neutrophil activation. Accordingly, neutrophils' side-fluorescence (NEUT-SFL), a Sysmex™ CBC analyzers parameter previously associated to NETosis (Stiel et al., 2016, Delabranche et al., 2017) was increased during septic shock induced DIC as well as following in-vitro ionomycin stimulation of normal PMNs. In this study, we showed for the first time direct evidence of circulating NETs in peripheral blood of patients with septic shock-induced DIC using immunofluorescence. These NETs are undistinguishable from NETs features observed following in-vitro ionomycin stimulation of normal PMNs. NETs images were furthermore associated with modifications of PMN morphology that could be detected using MGG staining. This observation may be of great interest in order to stratify patients eligible for future treatment protocols with molecules targeting NETs. Figure Disclosures Meziani: STAGO: Research Funding

Medium-chain triglyceride supplementation exacerbates peritonitis-induced septic shock in rats: role on cell membrane remodeling:

BACKGROUND AND AIMS: Lipid emulsions for parenteral nutrition interfere with immunity and may alter the cell plasma membrane and microparticle release, thus modulating their biological effects. Our aim was to evaluate the effect of two lipid emulsions for parenteral nutrition containing either a mixture of long- and medium-chain triglycerides (LCTs and MCTs) or LCTs only, to assess their role on microparticle release and acute inflammation during septic shock in rats. METHODS AND RESULTS: Septic rats (cecal ligation and puncture) and sham rats were infused with 5% dextrose or a lipid emulsion during 22 h. After 18 h, rats were resuscitated during 4 h and hemodynamic parameters monitored. Circulating microparticles and their phenotype were measured by prothrombinase assay; heart and aorta were collected for Western blotting and electron paramagnetic resonance measurements. No significant effect of lipid emulsions was observed in sham rats. In septic rats, norepinephrine requirements were increased in MCT/LCT-infused rats compared with 5% dextrose- or LCT-infused rats (2.7 +/- 0.2 vs. 1.9 +/- 0.8 and 1.2 +/- 0.3 mug/kg per minute, respectively; P < 0.05) with increased procoagulant microparticle generation (38.6 +/- 5.8 vs. 18.8 +/- 3.1 and 19.2 +/- 3.0 nM equivalent phosphatidylserine [Eq PhtdSer]; P < 0.05), leukocyte- (17.4 +/- 3.5 vs. 7.7 +/- 1.8 and 6.0 +/- 1.1 nM Eq PhtdSer; P < 0.05), platelet- (13.9 +/- 2.5 vs. 4.4 +/- 0.7 and 5.4 +/- 1.3 nM Eq PhtdSer; P < 0.05), and endothelial-derived microparticles (16.9 +/- 3.6 vs. 6.4 +/- 1.4 and 5.6 +/- 0.8 nM Eq PhtdSer; P < 0.05). The mixture of MCTs/LCTs significantly increased cardiac and vascular nitric oxide and superoxide anion production, phosphorylated IkappaB, and cyclooxygenase 2 expression compared with the lipid emulsion containing only LCTs. CONCLUSIONS: Compared with 5% dextrose, MCT/LCT supplementation during septic shock in rats induced deleterious effects with increased inflammation and cell activation, associated to vascular hyporeactivity. During septic shock, LCT supplementation seemed to be neutral compared with 5% dextrose infusion

Nicotine patches in patients on mechanical ventilation for severe COVID-19: a randomized, double-blind, placebo-controlled, multicentre trial

International audienceEpidemiologic studies have documented lower rates of active smokers compared to former or non-smokers in symptomatic patients affected by coronavirus disease 2019 (COVID-19). We assessed the efficacy and safety of nicotine administered by a transdermal patch in critically ill patients with COVID-19 pneumonia

Hydrocortisone plus fludrocortisone for community acquired pneumonia-related septic shock: a subgroup analysis of the APROCCHSS phase 3 randomised trial

International audienceBackground: Glucocorticoids probably improve outcomes in patients hospitalised for community acquired pneumonia (CAP). In this a priori planned exploratory subgroup analysis of the phase 3 randomised controlled Activated Protein C and Corticosteroids for Human Septic Shock (APROCCHSS) trial, we aimed to investigate responses to hydrocortisone plus fludrocortisone between CAP and non-CAP related septic shock.Methods: APROCCHSS was a randomised controlled trial that investigated the effects of hydrocortisone plus fludrocortisone, drotrecogin-alfa (activated), or both on mortality in septic shock in a two-by-two factorial design; after drotrecogin-alfa was withdrawn on October 2011, from the market, the trial continued on two parallel groups. It was conducted in 34 centres in France. In this subgroup study, patients with CAP were a preselected subgroup for an exploratory secondary analysis of the APROCCHSS trial of hydrocortisone plus fludrocortisone in septic shock. Adults with septic shock were randomised 1:1 to receive, in a double-blind manner, a 7-day treatment with daily administration of intravenous hydrocortisone 50 mg bolus every 6h and a tablet of 50 μg of fludrocortisone via the nasogastric tube, or their placebos. The primary outcome was 90-day all-cause mortality. Secondary outcomes included all-cause mortality at intensive care unit (ICU) and hospital discharge, 28-day and 180-day mortality, the number of days alive and free of vasopressors, mechanical ventilation, or organ failure, and ICU and hospital free-days to 90-days. Analysis was done in the intention-to-treat population. The trial was registered at ClinicalTrials.gov (NCT00625209).Findings: Of 1241 patients included in the APROCCHSS trial, CAP could not be ruled in or out in 31 patients, 562 had a diagnosis of CAP (279 in the placebo group and 283 in the corticosteroid group), and 648 patients did not have CAP (329 in the placebo group and 319 in the corticosteroid group). In patients with CAP, there were 109 (39%) deaths of 283 patients at day 90 with hydrocortisone plus fludrocortisone and 143 (51%) of 279 patients receiving placebo (odds ratio [OR] 0·60, 95% CI 0·43-0·83). In patients without CAP, there were 148 (46%) deaths of 319 patients at day 90 in the hydrocortisone and fludrocortisone group and 157 (48%) of 329 patients in the placebo group (OR 0·95, 95% CI 0·70-1·29). There was significant heterogeneity in corticosteroid effects on 90-day mortality across subgroups with CAP and without CAP (p=0·046 for both multiplicative and additive interaction tests; moderate credibility). Of 1241 patients included in the APROCCHSS trial, 648 (52%) had ARDS (328 in the placebo group and 320 in the corticosteroid group). There were 155 (48%) deaths of 320 patients at day 90 in the corticosteroid group and 186 (57%) of 328 patients in the placebo group. The OR for death at day 90 was 0·72 (95% CI 0·53-0·98) in patients with ARDS and 0·85 (0·61-1·20) in patients without ARDS (p=0·45 for multiplicative interaction and p=0·42 for additive interaction). The OR for observing at least one serious adverse event (corticosteroid group vs placebo) within 180 days post randomisation was 0·64 (95% CI 0·46-0·89) in the CAP subgroup and 1·02 (0·75-1·39) in the non-CAP subgroup (p=0·044 for multiplicative interaction and p=0·042 for additive interaction).Interpretation: In a pre-specified subgroup analysis of the APROCCHSS trial of patients with CAP and septic shock, hydrocortisone plus fludrocortisone reduced mortality as compared with placebo. Although a large proportion of patients with CAP also met criteria for ARDS, the subgroup analysis was underpowered to fully discriminate between ARDS and CAP modifying effects on mortality reduction with corticosteroids. There was no evidence of a significant treatment effect of corticosteroids in the non-CAP subgroup.Funding: Programme Hospitalier de Recherche Clinique of the French Ministry of Health, by Programme d'Investissements d'Avenir, France 2030, and IAHU-ANR-0004