Retrospective study of anaesthetic management of pregnancy patients with mechanical heart valve prosthesis and anticoagulants

Pregnancies among patients with a mechanical prosthetic valve and receiving anticoagulant medication are rare. Informations about their anesthetic management is poor. The objective of this study was to investigate the anaesthetic management of these patients in a reference medical centre as well as to identify possible ways for improvement. To this aim, the medical records of patients with a mechanical heart valve prosthesis having given birth at our center were analysed. In particular, the characteristics of patients and deliveries, the management of anticoagulation, as well as the type of anaesthesia performed, were collected and analysed. Eighteen cases were studied and compared to 36 controls. All studied cases were being administered anticoagulants. Five of these 8 patients delivered vaginally, one with epidural analgesia. Three of them have had a caesarean during labor, all under general anaesthesia. During the anticoagulation window, the teams had to perform an epidural in 3 (37%) of these 8 patients. Ten cases (55%) had a planned caesarean delivery, all performed under general anaesthesia. The anticoagulation interruption allowed spinal anaesthesia for 4 out of 10 caesarean delivery. The reoperation rate for secondary haemorrhage was significantly higher (P=0.0032) and the duration of the hospitalisation was extended (P<0.001). A context of anticoagulant overdose was identified in 60% of the bleeding cases. Progress can be made in the anaesthetic management of those patients by optimising the use of neuraxial anaesthesia and by improving the management of bleeding risk after delivery

Antimicrobial Treatmdent of "Complicated" Intra-Abdominal Infections and The New IDSA Guidelines - A Commentary and an Alternative European Approach According to Clinical Definitions

Recently, an update of the IDSA guidelines for the treatment of complicated intraabdominal infections has been published. No guideline can cater for all variations in ecology, antimicrobial resistance patterns, patient characteristics and presentation, health care and reimbursement systems in many different countries. In the short time the IDSA guidelines have been available, a number of practical clinical issues have been raised by physicians regarding interpretation of the guidelines. The main debatable issues of the new IDSA guidelines are described as follows

Comparison of albicans vs. non-albicans candidemia in French intensive care units

The AmarCand Study Group (ICU physicians): Drs. Allaouchiche (Lyon), Amigues (Montpellier), Ausseur (Saint Herblain), Azoulay (Paris), Badet (Lyon), Baldesi (Aix-en-Provence), Bastien (Bron), Baudin (Paris), Bayle (Lyon), Bazin (Clermont-Ferrand), Benayoun (Clichy), Blondeau (Roubaix), Bodin (Paris), Bollaert (Nancy), Bonadona (La Tronche), Bonnaire (Aulnay Sous Bois), Bonnivard (Montauban), Borne (Paris), Brabet (Montpellier), Branche (Lyon), Braud (Rouen), Bret (Lyon), Bretonnière (Nantes), Brocas (Evry), Brun (Bron), Bruneel (Versailles), Canevet (Armentières), Cantais (Toulon Armées), Carlet (Paris), Charbonneau (Caen), Charles (Dijon), Chastagner (Chamberry), Corne (Montpellier), Courte (Saint-Brieuc), Cousson (Reims), Cren (Morlaix), Diconne (Saint Etienne), Drouet (Saint-Denis), Dube (Angers), Duguet (Paris), Dulbecco (Antibes), Dumenil (Clamart), Dupont (Amiens), Durand (Grenoble), Durand-Gasselin (Toulon), Durocher (Lille), Fangio (Poissy), Fattouh (Mulhouse), Favier (Metz Armées), Fieux (Paris), Fleureau (Pessac), Freys (Strasbourg), Fulgencio (Paris), Gally (Mulhouse), Garnaud (Orléans), Garot (Tours), Gilhodes (Créteil), Girault (Rouen), Gouin (Marseille), Gouin (Rouen), Guidon (Marseille), Hérault (Grenoble), Hyvernat (Nice), Jobard (Monaco), Jospe (Saint Etienne), Kaidomar (Fréjus), Karoubi (Bobigny), Kherchache (Agen), Lacherade (Poissy), Lakermi (Paris), Lambiotte (Maubeuge), Lamia (Le Kremlin-Bicêtre), Lasocki (Paris), Launoy (Strasbourg), Le Guillou (Paris), Lefort (Saint-Denis), Lefrant (Nîmes), Lemaire (Roubaix), Lepape (Pierre-Bénite), Lepoutre (Lomme), Leroy (Lille), Leroy (Tourcoing), Loriferne (Bry-sur-Marne), Mahe (Nantes), Mandin (Gap), Marighy (Saint- Denis), Mathieu (Lille), Mathonnet (Paris), Megarbane (Paris), Mercat (Angers), Michel (Saint Herblain), Michelet (Marseille), Mimoz (Poitiers), Mohammedi (Lyon), Mouquet (Paris), Mourvillier (Paris), Navellou (Besançon), Novara (Paris), Obadia (Montreuil), Perrigault (Montpellier), Perrin (Marseille), Petit (Valence), Poussel (Metz), Rahmani (Strasbourg), Renard (La Roche sur Yon), Robert (Poitiers), Robert (Lyon), Saliba (Villejuif ), Sannini (Marseille), Santré (Annecy), Seguin (Rennes), Souweine (Clermont-Ferrand), Trouillet (Paris), Valentin (Besançon), Volatron (Rennes), Voltz (Vandoeuvre les Nancy), Winer (Saint Pierre), and Winnock (Bordeaux).International audienceINTRODUCTION: Candidemia raises numerous therapeutic issues for intensive care physicians. Epidemiological data that could guide the choice of initial therapy are still required. This analysis sought to compare the characteristics of intensive care unit (ICU) patients with candidemia due to non-albicans Candida species with those of ICU patients with candidemia due to Candida albicans. METHODS: A prospective, observational, multicenter, French study was conducted from October 2005 to May 2006. Patients exhibiting candidemia developed during ICU stay and exclusively due either to one or more non-albicans Candida species or to C. albicans were selected. The data collected included patient characteristics on ICU admission and at the onset of candidemia. RESULTS: Among the 136 patients analyzed, 78 (57.4%) had candidemia caused by C. albicans. These patients had earlier onset of infection (11.1 +/- 14.2 days after ICU admission vs. 17.4 +/- 17.7, p = 0.02), higher severity scores on ICU admission (SOFA: 10.4 +/- 4.7 vs. 8.6 +/- 4.6, p = 0.03; SAPS II: 57.4 +/- 22.8 vs. 48.7 +/- 15.5, P = 0.015), and were less often neutropenic (2.6% vs. 12%, p = 0.04) than patients with candidemia due to non-albicans Candida species. CONCLUSIONS: Although patients infected with Candida albicans differed from patients infected with non-albicans Candida species for a few characteristics, no clinical factor appeared pertinent enough to guide the choice of empirical antifungal therapy in ICU

Assessment of pain during labor with pupillometry: a prospective observational study.: Pupillometry and labor pain

International audienceBACKGROUND: Pain intensity is usually self-rated by patients with a numeric rating scale (NRS) but this scale cannot be used for noncommunicating patients. In anesthetized patients, experimental noxious stimulus increases pupillary diameter (PD) and pupillary light reflex amplitude (PLRA), the difference between PD before and after light stimulation. Labor pain is an intense acute nonexperimental stimulus, effectively relieved by epidural analgesia. In this prospective observational study, we therefore describe the effects of labor pain and pain relief with epidural analgesia on PD and PLRA, determine their association with pain intensity and determine the ability of a single measurement of PD or PLRA to assess pain. METHODS: In the first stage, pain (11-point NRS), PD, and PLRA were measured in 4 conditions in 26 laboring women: before and after epidural analgesia and in the presence and absence of a uterine contraction. Pupillometry values among the 4 conditions were compared, and the strength of the association between absolute values of pain and PD or PLRA and between pain and changes in PD or PLRA brought about by uterine contraction was assessed with r(2). In the second stage, 1 measurement was performed in 104 laboring women. The strength of the association between pain and PD or PLRA was assessed with r(2). The ability of PD or PLRA to discriminate pain (NRS > 4) was also assessed. RESULTS: In the first stage, a statistically significant increase in pain, PD, and PLRA was observed during a contraction, and this change was abolished after epidural analgesia. The r(2) for the association between pain and changes in PD (r(2) = 0.25 [95% confidence interval, 0.07-0.46] or PLRA (r(2) = 0.34 [0.14-0.56]) brought about by a uterine contraction was higher than the r(2) for the association between pain and absolute values of PD (r(2) = 0.14 [0.04-0.28]) or PLRA (r(2) = 0.22 [0.10-0.37]) suggesting a stronger association for changes than for absolute values. In the second stage, r(2) was 0.23 [0.10-0.38] for PD and 0.26 [0.11-0.40] for PLRA and the area under the receiver operating characteristics curve was 0.82 [0.73-0.91] and 0.80 [0.71-0.89], respectively. CONCLUSIONS: Changes in PD and PLRA brought about by a uterine contraction may be used as a tool to assess analgesia in noncommunicating patients

Clinical review: Intrapericardial fibrinolysis in management of purulent pericarditis

Purulent pericarditis (PP) is a potentially life-threatening disease. Reported mortality rates are between 20 and 30%. Constrictive pericarditis occurs over the course of PP in at least 3.5% of cases. The frequency of persistent PP (chronic or recurrent purulent pericardial effusion occurring despite drainage and adequate antibiotherapy) is unknown because this entity was not previously classified as a complication of PP. No consensus exists on the optimal management of PP. Nevertheless, the cornerstone of PP management is complete eradication of the focus of infection. In retrospective studies, compared to simple drainage, systematic pericardiectomy provided a prevention of constrictive pericarditis with better clinical outcome. Because of potential morbidity associated with pericardiectomy, intrapericardial fibrinolysis has been proposed as a less invasive method for prevention of persistent PP and constrictive pericarditis. Experimental data demonstrate that fibrin formation, which occurs during the first week of the disease, is an essential step in the evolution to constrictive pericarditis and persistent PP. We reviewed the literature using the MEDLINE database. We evaluated the clinical efficacy, outcome, and complications of pericardial fibrinolysis. Seventy-four cases of fibrinolysis in PP were analysed. Pericarditis of tuberculous origin were excluded. Among the 40 included cases, only two treated by late fibrinolysis encountered failure requiring pericardiectomy. No patient encountered clinical or echocardiographic features of constriction during follow-up. Only one serious complication was described. Despite the lack of definitive evidence, potential benefits of fibrinolysis as a less invasive alternative to surgery in the management of PP seem promising. Early consideration should be given to fibrinolysis in order to prevent both constrictive and persistent PP. Nevertheless, in case of failure of fibrinolysis, pericardiectomy remains the primary option for complete eradication of infection

Strategies of initiation and streamlining of antibiotic therapy in 41 French intensive care units

CIAR (Club d'infectiologie en Anesthésie-Réanimation) Study Group: Pr B Allaouchiche (HCL, CHU Lyon), Pr C Arich (CHU Nimes), Pr C Auboyer (CHU St-Etienne), Dr JP Caramella (CHG Nevers), Dr JF Cochard (CHU Bordeaux), Dr A Combes (CHG Meaux), Dr P Courant (CHG Avignon), Dr J Durand-Gasselin (CHG Toulon), Pr J Duranteau (APHP, CHU Bicetre), Dr H Floch (CHU Nantes), Dr F Fraisse (CHG St Denis), Pr M Freysz (CHU Dijon), Dr B Garrigues (CHG Aix-en-Provence), Dr B Georges (CHU Toulouse), Pr F Gouin (APHM, CHU Marseille), Pr L Jacob (APHP, CHU St Louis), Pr P Juvin (APHP, CHU Beaujon), Dr J Keinlen (CHU Montpellier), Dr AM Korinek (APHP, CHU Pitie Salpetriere), Dr C Lamer (Institut Mutualiste Montsouris, Paris), Pr JY Lefrant (CHU Nimes), Dr O Lesieur (CHG La Rochelle), Dr Yazine Mahjoub (CHU Amiens), Pr Y Malledant (CHU Rennes), Pr C Martin (APHM, CHU Marseille), Pr O Mimoz (CHU Poitiers), Pr C Paugam-Burtz (APHP, CHU Beaujon, Clichy), Dr PF Perrigault (CHU Montpellier), Pr T Pottecher (CHU Strasbourg), Pr JL Pourriat (APHP, CHU Hotel Dieu), Dr JF Poussel (CHG Metz), Dr A Rabbat (APHP, CHU Hotel Dieu), Dr J Reignier (CHG La Roche sur Yon), Dr P Sichel (CHG Cherbourg), Dr JP Sollet (CHG Argenteuil), Dr D Thevenin (CHG Lens), Dr G Viquesnel (CHU Caen).International audienceINTRODUCTION: Few studies have addressed the decision-making process of antibiotic therapy (AT) in intensive care unit (ICU) patients. METHODS: In a prospective observational study, all consecutive patients admitted over a one-month period (2004) to 41 French surgical (n = 22) or medical/medico-surgical ICUs (n = 19) in 29 teaching university and 12 non-teaching hospitals were screened daily for AT until ICU discharge. We assessed the modalities of initiating AT, reasons for changes and factors associated with in ICU mortality including a specific analysis of a new AT administered on suspicion of a new infection. RESULTS: A total of 1,043 patients (61% of the cohort) received antibiotics during their ICU stay. Thirty percent (509) of them received new AT mostly for suspected diagnosis of pneumonia (47%), bacteremia (24%), or intra-abdominal (21%) infections. New AT was prescribed on day shifts (45%) and out-of-hours (55%), mainly by a single senior physician (78%) or by a team decision (17%). This new AT was mainly started at the time of suspicion of infection (71%) and on the results of Gram-stained direct examination (21%). Susceptibility testing was performed in 261 (51%) patients with a new AT. This new AT was judged inappropriate in 58 of these 261 (22%) patients. In ICUs with written protocols for empiric AT (n = 25), new AT prescribed before the availability of culture results (P = 0.003) and out-of-hours (P = 0.04) was more frequently observed than in ICUs without protocols but the appropriateness of AT was not different. In multivariate analysis, the predictive factors of mortality for patients with new AT were absence of protocols for empiric AT (adjusted odds ratio (OR) = 1.64, 95% confidence interval (95%CI): 1.01 to 2.69), age ≥60 (OR = 1.97, 95% CI: 1.19 to 3.26), SAPS II score >38 (OR = 2.78, 95% CI: 1.60 to 4.84), rapidly fatal underlying diseases (OR = 2.91, 95% CI: 1.52 to 5.56), SOFA score ≥6 (OR = 4.48, 95% CI: 2.46 to 8.18). CONCLUSIONS: More than 60% of patients received AT during their ICU stay. Half of them received new AT, frequently initiated out-of-hours. In ICUs with written protocols, empiric AT was initiated more rapidly at the time of suspicion of infection and out-of-hours. These results encourage the establishment of local recommendations for empiric AT

IGNITE4 : Results of a phase 3, randomized, multicenter, prospective trial of eravacycline vs meropenem in the treatment of complicated intraabdominal infections

Funding Information: Financial support. This work was supported by Tetraphase Pharmaceuticals Inc. Funding Information: Potential conflicts of interest. J. S. S. has received support from Tetraphase Pharmaceuticals Inc. during the production of this manuscript and has served as a consultant to Merck, Pfizer, GlaxoSmithKline, and Melinta outside of the submitted work. A. S received support from Tetraphase Pharmaceuticals Inc. during the production of this manuscript. J. G. received research funding from Tetraphase Pharmaceuticals Inc. for his role as principal investigator of this study. K. L. and L. T. are employed by Tetraphase Pharmaceuticals Inc. D. E. reports grants from Tetraphase Pharmaceuticals Inc. during the conduct of the study and grants from Merck outside of the submitted work. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. Publisher Copyright: © 2018 The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America.Background: Increasing antimicrobial resistance among pathogens that cause complicated intraabdominal infections (cIAIs) supports the development of new antimicrobials. Eravacycline, a novel member of the fluorocycline family, is active against multidrug-resistant bacteria including extended-spectrum β-lactamase (ESBL) and carbapenem-resistant Enterobacteriaceae. Methods: IGNITE4 was a prospective, randomized, double-blind trial. Hospitalized patients with cIAI received either eravacycline 1 mg/kg every 12 hours or meropenem 1 g every 8 hours intravenously for 4-14 days. The primary objective was to demonstrate statistical noninferiority (NI) in clinical cure rates at the test-of-cure visit (25-31 days from start of therapy) in the microbiological intent-to-treat population using a NI margin of 12.5%. Microbiological outcomes and safety were also evaluated. Results: Eravacycline was noninferior to meropenem in the primary endpoint (177/195 [90.8%] vs 187/205 [91.2%]; difference, -0.5%; 95% confidence interval [CI], -6.3 to 5.3), exceeding the prespecified margin. Secondary endpoints included clinical cure rates in the modified ITT population (231/250 [92.4%] vs 228/249 [91.6%]; difference, 0.8; 95% CI, -4.1, 5.8) and the clinically evaluable population (218/225 [96.9%] vs 222/231 [96.1%]; (difference, 0.8; 95% CI -2.9, 4.5). In patients with ESBL-producing Enterobacteriaceae, clinical cure rates were 87.5% (14/16) and 84.6% (11/13) in the eravacycline and meropenem groups, respectively. Eravacycline had relatively low rates of adverse events for a drug of this class, with less than 5%, 4%, and 3% of patients experiencing nausea, vomiting, and diarrhea, respectively. Conclusions: Treatment with eravacycline was noninferior to meropenem in adult patients with cIAI, including infections caused by resistant pathogens. Clinical Trials Registration: NCT01844856.publishersversionPeer reviewe

Efficacy and toxicity of intravenous iron in a mouse model of critical care anemia

OBJECTIVE: Anemia is common in critically ill patients, due to inflammation and blood loss. Anemia can be associated with iron deficiency and low serum hepcidin levels. However, iron administration in this setting remains controversial because of its potential toxicity, including oxidative stress induction and sepsis facilitation. The objective of this work was to determine the efficacy and toxicity of iron administration using a mouse model mimicking critical care anemia as well as a model of acute septicemia. DESIGN: Prospective, randomized, open label controlled animal study. SETTING: University-based research laboratory. SUBJECTS: C57BL/6 and OF1 mice. INTERVENTIONS: Intraperitoneal injection of zymosan inducing generalized inflammation in C57BL/6 mice, followed in our full model by repeated phlebotomies. A dose equivalent to 15 mg/kg of ferric carboxymaltose was injected intravenously on day 5. To assess the toxicity of iron in a septicemia model, OF1 mice were simultaneously injected with iron and different Escherichia coli strains. MEASUREMENTS AND MAIN RESULTS: To investigate the effect of iron on oxidative stress, we measured reactive oxygen species production in the blood using luminol-amplified chemiluminescence and superoxide dismutase 2 messenger RNA levels in the liver. These markers of oxidative stress were increased after iron administration in control mice but not in zymosan-treated mice. Liver catalase messenger RNA levels decreased in iron-treated control mice. Iron administration was not associated with increased mortality in the septicemia model or in the generalized inflammation model. Iron increased hemoglobin levels in mice fed with a low iron diet and subjected to phlebotomies and zymosan 2 wks after treatment administration. CONCLUSIONS: Adverse effects of intravenous iron supplementation by ferric carboxymaltose seem to be minimal in our animal models. Furthermore, iron appears to be effective in correcting anemia, despite inflammation. Studies of efficacy and safety of iron in critically ill patients are warranted