Signification clinique et pronostique de l'anémie dans le syndrome coronaire aigu

LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Use of sodium-chloride difference and corrected anion gap as surrogates of Stewart variables in critically ill patients.

INTRODUCTION: To investigate whether the difference between sodium and chloride ([Na(+)] - [Cl(-)]) and anion gap corrected for albumin and lactate (AG(corr)) could be used as apparent strong ion difference (SID(app)) and strong ion gap (SIG) surrogates (respectively) in critically ill patients. METHODS: A total of 341 patients were prospectively observed; 161 were allocated to the modeling group, and 180 to the validation group. Simple regression analysis was used to construct a mathematical model between SID(app) and [Na(+)] - [Cl(-)] and between SIG and AG(corr) in the modeling group. Area under the receiver operating characteristic (ROC) curve was also measured. The mathematical models were tested in the validation group. RESULTS: in the modeling group, SID(app) and SIG were well predicted by [Na(+)] - [Cl(-)] and AG(corr) (R(2) = 0.973 and 0.96, respectively). Accuracy values of [Na(+)] - [Cl(-)] for the identification of SID(app) acidosis (47.5 mEq/L) were 0.992 (95% confidence interval [CI], 0.963-1) and 0.998 (95%CI, 0.972-1), respectively. The accuracy of AG(corr) in revealing SIG acidosis (>8 mEq/L) was 0.974 (95%CI: 0.936-0.993). These results were validated by showing excellent correlations and good agreements between predicted and measured SID(app) and between predicted and measured SIG in the validation group (R(2) = 0.977; bias = 0±1.5 mEq/L and R(2) = 0.96; bias = -0.2±1.8 mEq/L, respectively). CONCLUSIONS: SID(app) and SIG can be substituted by [Na(+)] - [Cl(-)] and by AG(corr) respectively in the diagnosis and management of acid-base disorders in critically ill patients

Determinants of noninvasive ventilation success or failure in morbidly obese patients in acute respiratory failure.

PurposeAcute respiratory failure (ARF) is a common life-threatening complication in morbidly obese patients with obesity hypoventilation syndrome (OHS). We aimed to identify the determinants of noninvasive ventilation (NIV) success or failure for this indication.MethodsWe prospectively included 76 consecutive patients with BMI>40 kg/m2 diagnosed with OHS and treated by NIV for ARF in a 15-bed ICU of a tertiary hospital.ResultsNIV failed to reverse ARF in only 13 patients. Factors associated with NIV failure included pneumonia (n = 12/13, 92% vs n = 9/63, 14%; pConclusionsMultiple organ failure and pneumonia were the main factors associated with NIV failure and death in morbidly obese patients in hypoxemic ARF. On the opposite, NIV was constantly successful and could be safely pushed further in case of severe hypercapnic acute respiratory decompensation of OHS

Subgroups analysis of acid-base variables, agreements and intraclass correlation coefficients between observed and predicted values of SID_app and of SIG, and kappa coefficients between SID_app and its surrogate and between SIG and its surrogate in the cross-validation group.

<p>SID_app, apparent strong ion difference; SIG, strong ion gap; AG_corr, anion gap corrected for albumin and lactate; ICC, intraclass correlation coefficient; CI, confidence interval. Metabolic acidosis = SBE<−2 mEq/L, reference range = −2 mEq/L≤SBE≤+2 mEq/L, and metabolic alkalosis = SBE>+2 mEq/L. Agreement is expressed as bias, (95% limits of agreement). All others data are expressed as median with range (minimum, maximum).</p

Subgroups analysis in the septic shock patients of the cross-validation group according to the presence of acute kidney injury and of acute respiratory failure.

<p>AKI, acute kidney injury; ARF, acute respiratory failure, SID_app, apparent strong ion difference; SIG, strong ion gap; AG_corr, anion gap corrected for albumin and lactate; ICC, intraclass correlation coefficient; CI, confidence interval. Agreement is expressed as bias, (95% limits of agreement).</p

Correlation and agreement between observed and predicted strong ion gap (SIG) in the cross-validation group.

<p>Panel A shows the agreement between observed and predicted SIG (bias = −0.2, limits of agreement 95% = −2.1 to 1.6 mEq/L). Panel B shows the correlation between observed and predicted SIG (R2 = 0.96, P<0.0001).</p

Sensitivity, specificity, likelihood ratios, and accuracy of apparent strong ion difference (SID_app) surrogate in the presence of Hyponatremia (Na⁺<135 mEq/L) (n = 57).

<p>LHR⁺, positive likelihood ratio; LHR⁻, negative likelihood ratio; CI, confidence interval.</p

Patients characteristics at admission.

<p>Abbreviations: BMI, body mass index; NIV, non-invasive ventilation; ARF, acute respiratory failure; MRC, Medical Research Council dyspnea score; OSAS, obstructive sleep apnea syndrome; DNI status, do-not-intubate status; SAPS 2, simplified acute physiologic score 2; SOFA score, sequential organ failure assessment score; SABP, systolic arterial blood pressure.</p

Arterial blood gases at the time of noninvasive ventilation (NIV) initiation (H0), after 2 hrs of NIV (H2), and at the time of NIV failure (failure) in patients of the early NIV failure group (n = 13, left column).

<p>By comparison, arterial blood gases evolution during the first 48(n = 30, central column) and in patients with a delayed response to NIV (n = 33, right column).</p