30 research outputs found

    Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

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    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/)

    Management and prognostic factors of acute circulatory failure in patients with Pulmonary Arterial Hypertension

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    L’hypertension artérielle pulmonaire (HTAP) est une maladie caractérisée par une obstruction des artères pulmonaires de petit calibre aboutissant, à terme, à une défaillance cardiaque droite. L’évolution de cette maladie est parfois émaillée d’épisodes de dégradation de l’état fonctionnel des patients, nécessitant une admission en unité de soins intensifs pour surveillance cardioscopique et administration de médicaments inotropes et/ou vasopresseurs. Peu d’éléments permettent à ce jour de guider les praticiens dans la prise en charge de ces patients et la physiopathologie de ces épisodes est assez peu connue.Dans un premier temps, nous avons retrouvé une mortalité de 41% en réanimation et testé certains facteurs pronostiques cliniques et biologiques simples issus de la pratique quotidienne dans une cohorte propective de patients avec une prise en charge standardisée. Nous avons identifié comme facteurs pronostiques la pression artérielle systémique, la natrémie, la créatininémie, la valeur de la C-reactive Proteine. Nous avons retrouvé une influence de ces épisodes sur l’évolution à moyen terme de ces épisodes. Dans un second temps nous avons testé la valeur pronostique des indices temporels de fonctionnement du ventricule gauche, suggérée par les études en imagerie par résonnance magnétique. Nous avons utilisé pour cela la tonométrie d’aplanation, outil original et non invasif. Nous avons retrouvé que la valeur de la durée d’éjection du ventricule gauche est associée au pronostic. Dans une troisième partie nous avons mesuré les conséquences et la valeur pronostique de l’épuration extra rénale en contexte d’ insuffisance rénale menaçante chez ces patients. Dans une étude rétrospective, nous avons observé 68 séances d’épuration extra-rénale continue ou discontinue. Ces séances se sont compliquées d’hypotension artérielle dans environ 50% des cas. La très haute mortalité en réanimation et à 3 mois, respectivement de 47% et 73%, soulève la question de la place de l’assistance circulatoire et de la transplantation urgente chez ces patients. Ces données soulignent la sévérité à court terme des épisodes aigus d’aggravation chez les patients porteurs d’HTAP. De plus amples données sont nécessaires pour améliorer la prise en charge de ces patients et organiser dans le meilleur délai la mise en place de thérapeutiques exceptionnelles comme l’assistance circulatoire et la transplantation pulmonaire ou cardio-pulmonaire.Pulmonary arterial hypertension ( PAH) is a disease characterized by an obstruction of the small pulmonary arteries leading ultimately to right heart failure. The evolution of this disease is sometimes punctuated by episodes of deterioration of the functional status of patients requiring admission to intensive care unit for monitoring and administration of inotropic drugs and / or vasopressors. Few evidence to date are available to guide physicians in the care of these patients and the pathophysiology of these episodes is still elusive.In a first part, we found a mortality of 41% in the intensive care unit (ICU) and tested some simple clinical and biological prognostic factors from the daily practice in a prospective cohort of patients with a standardized management. We have identified systemic blood pressure, serum sodium, serum creatinine, serum C -reactive Protein as prognostic factors. We found an influence of these events on the medium-term evolution of the patients.In a second step we tested the prognostic value of time derived indices of left ventricular function, variables suggested by magnetic resonance imaging studies. In this purpose, we used aplanation tonometry, an original and non-invasive tool. We found that the value of the left ventricular ejection time was associated with in ICU prognosis.In the third part we measured the impact and prognostic value of renal replacement therapy in case of threatening kidney failure in these patients. In a retrospective study, we observed 68 sessions of renal replacement therapy, continuous hemofiltration and intermittent hemodialysis. These sessions were complicated by hypotension in 50 % of cases. The high in ICU mortality and three months mortilty, respectively 47% and 73%, raises the question of the role of extracorporeal life support and urgent transplantation in these patients.These data underscore the severity of acute worsening in patients with PAH. More data are needed to improve the management of these patients and determine the best timing of exceptional treatment such as circulatory support and pulmonary or cardiopulmonary transplantation

    Prise en charge et facteurs pronostiques des épisodes d'insuffisance circulatoire aiguë chez des patients atteints d'Hypertension Artérielle pulmonaire

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    Pulmonary arterial hypertension ( PAH) is a disease characterized by an obstruction of the small pulmonary arteries leading ultimately to right heart failure. The evolution of this disease is sometimes punctuated by episodes of deterioration of the functional status of patients requiring admission to intensive care unit for monitoring and administration of inotropic drugs and / or vasopressors. Few evidence to date are available to guide physicians in the care of these patients and the pathophysiology of these episodes is still elusive.In a first part, we found a mortality of 41% in the intensive care unit (ICU) and tested some simple clinical and biological prognostic factors from the daily practice in a prospective cohort of patients with a standardized management. We have identified systemic blood pressure, serum sodium, serum creatinine, serum C -reactive Protein as prognostic factors. We found an influence of these events on the medium-term evolution of the patients.In a second step we tested the prognostic value of time derived indices of left ventricular function, variables suggested by magnetic resonance imaging studies. In this purpose, we used aplanation tonometry, an original and non-invasive tool. We found that the value of the left ventricular ejection time was associated with in ICU prognosis.In the third part we measured the impact and prognostic value of renal replacement therapy in case of threatening kidney failure in these patients. In a retrospective study, we observed 68 sessions of renal replacement therapy, continuous hemofiltration and intermittent hemodialysis. These sessions were complicated by hypotension in 50 % of cases. The high in ICU mortality and three months mortilty, respectively 47% and 73%, raises the question of the role of extracorporeal life support and urgent transplantation in these patients.These data underscore the severity of acute worsening in patients with PAH. More data are needed to improve the management of these patients and determine the best timing of exceptional treatment such as circulatory support and pulmonary or cardiopulmonary transplantation.L’hypertension artérielle pulmonaire (HTAP) est une maladie caractérisée par une obstruction des artères pulmonaires de petit calibre aboutissant, à terme, à une défaillance cardiaque droite. L’évolution de cette maladie est parfois émaillée d’épisodes de dégradation de l’état fonctionnel des patients, nécessitant une admission en unité de soins intensifs pour surveillance cardioscopique et administration de médicaments inotropes et/ou vasopresseurs. Peu d’éléments permettent à ce jour de guider les praticiens dans la prise en charge de ces patients et la physiopathologie de ces épisodes est assez peu connue.Dans un premier temps, nous avons retrouvé une mortalité de 41% en réanimation et testé certains facteurs pronostiques cliniques et biologiques simples issus de la pratique quotidienne dans une cohorte propective de patients avec une prise en charge standardisée. Nous avons identifié comme facteurs pronostiques la pression artérielle systémique, la natrémie, la créatininémie, la valeur de la C-reactive Proteine. Nous avons retrouvé une influence de ces épisodes sur l’évolution à moyen terme de ces épisodes. Dans un second temps nous avons testé la valeur pronostique des indices temporels de fonctionnement du ventricule gauche, suggérée par les études en imagerie par résonnance magnétique. Nous avons utilisé pour cela la tonométrie d’aplanation, outil original et non invasif. Nous avons retrouvé que la valeur de la durée d’éjection du ventricule gauche est associée au pronostic. Dans une troisième partie nous avons mesuré les conséquences et la valeur pronostique de l’épuration extra rénale en contexte d’ insuffisance rénale menaçante chez ces patients. Dans une étude rétrospective, nous avons observé 68 séances d’épuration extra-rénale continue ou discontinue. Ces séances se sont compliquées d’hypotension artérielle dans environ 50% des cas. La très haute mortalité en réanimation et à 3 mois, respectivement de 47% et 73%, soulève la question de la place de l’assistance circulatoire et de la transplantation urgente chez ces patients. Ces données soulignent la sévérité à court terme des épisodes aigus d’aggravation chez les patients porteurs d’HTAP. De plus amples données sont nécessaires pour améliorer la prise en charge de ces patients et organiser dans le meilleur délai la mise en place de thérapeutiques exceptionnelles comme l’assistance circulatoire et la transplantation pulmonaire ou cardio-pulmonaire

    Constipation in critical care patients: both timing and duration matter

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    International audienceObjective Most of the studies have defined constipation as a period without stool after ICU admission. We aimed to test the impact of both duration and timing of infrequent defecation in critical care patients. Patients and methods We performed a prospective, bi-center, observational study. Patients were divided into three subgroups: ‘not constipated’, ‘3–5 days’, and ‘at least 6 days’ (longest period without stool passage, respectively, shorter than 3 days, 3–5 days, and ≥6 days). Furthermore, ‘early’ constipated patients were defined as those for whom the longest time to stool passage occurred just after ICU admission, whereas for ‘late’ constipated patients the longest period without stool occurred later during ICU stay. Results A total of 182 patients were included: the mean age was 67.2 years (54.4–78.9 years), 80 were women, and simplified acute physiology score II was 42 (34–52). In all, 42 (23.1%), 82 (45.1%), and 58 (31.8%) belonged to the nonconstipated, 3–5 days, or greater than or equal to 6 days subgroup of patients, respectively. Time spent under mechanical ventilation and ICU length of stay was longer in the greater than or equal to 6 days subgroups as compared with both other subgroups. ICU stay was longer in the 3–5 days subgroup as compared with the not constipated patients. Furthermore, the late patients of the greater than or equal to 6 days subgroups exhibited worse survival as compared with all other patients. Conclusion Both timing and duration of infrequent defecation seem to have an impact on critical care patient’s outcome, and should therefore be included in the diagnostic criteria

    An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy

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    International audienceRationale: One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation.Objectives: To validate the diagnostic accuracy of an index (termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/FiO2 to respiratory rate) for determining HFNC outcome (need or not for intubation).Methods: This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed.Measurements and Main Results: Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264-0.715; P = 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182-0.509; P Conclusions: In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation. Clinical trial registered with www.clinicaltrials.gov (NCT02845128)

    Loxapine to control agitation during weaning from mechanical ventilation

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    Abstract Background Weaning from mechanical ventilation (MV) may be impeded by the occurrence of agitation. Loxapine has the ability to control agitation without affecting spontaneous ventilation. The aim of this study was to establish whether loxapine would reduce MV weaning duration in agitated patients. Methods We performed a multicentre, double-blind, placebo-controlled, parallel group, randomised trial. Patients who were potential candidates for weaning but exhibited agitation (Richmond Agitation-Sedation Scale score ≥ 2) after sedation withdrawal were randomly assigned to receive either loxapine or placebo. In case of severe agitation, conventional sedation was immediately resumed. The primary endpoint was the time between first administration of loxapine or placebo and successful extubation. Results The trial was discontinued after 102 patients were enrolled because of an insufficient inclusion rate. Median times to successful extubation were 3.2 days in the loxapine group and 5 days in the placebo group (relative risk 1.2, 95% CI 0.75–1.88, p = 0.45). During the first 24 h, sedation was more frequently resumed in the placebo group (44% vs 17%, p = 0.01). Conclusions In this prematurely stopped trial, loxapine did not significantly shorten weaning from MV. However, loxapine reduced the need for resuming sedation. Trial registration Clinicaltrials.gov, NCT01193816 . Registered on 26 August 2010
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