A multimodal tissue perfusion measurement approach for the evaluation of the effect of pimobendan, an inodilator, in a porcine sepsis model

Sepsis is associated with hypoperfusion and organ failure. The aims of the study were: 1) to assess the effect of pimobendan on macrocirculation and perfusion and 2) to describe a multimodal approach to the assessment of perfusion in sepsis and compare the evolution of the perfusion parameters. Eighteen anaesthetized female piglets were equipped for macrocirculation monitoring. Sepsis was induced by an infusion of Pseudomonas aeruginosa. After the occurrence of hypotension, animals were resuscitated. Nine pigs received pimobendan at the start of resuscitation maneuvers, the others received saline. Tissue perfusion was assessed using temperature gradients measured with infrared thermography (TG = core temperature - tarsus temperature), urethral perfusion index (uPI) derived from photoplethysmography and sublingual microcirculation (Sidestream dark field imaging device): De Backer score (DBs), proportion of perfused vessels (PPV), microvascular flow index (MFI) and heterogeneity index (HI). Arterial lactate and ScvO2 were also measured. Pimobendan did not improve tissue perfusion nor macrocirculation. It did not allow a reduction in the amount of noradrenaline and fluids administered. Sepsis was associated with tissue perfusion disorders: there were a significant decrease in uPI, PPV and ScvO2 and a significant rise in TG. TG could significantly predict an increase in lactate. Resuscitation was associated with a significant increase in uPI, DBs, MFI, lactate and ScvO2. There were fair correlations between the different perfusion parameters. In this model, pimobendan did not show any benefit. The multimodal approach allowed the detection of tissue perfusion alteration but only temperature gradients predicted the increase in lactatemia.

Comparison of mortality and outcomes of four respiratory viruses in the intensive care unit: a multicenter retrospective study

This retrospective study aimed to compare the mortality and burden of respiratory syncytial virus (RSV group), SARS-CoV-2 (COVID-19 group), non-H1N1 (Seasonal influenza group) and H1N1 influenza (H1N1 group) in adult patients admitted to intensive care unit (ICU) with respiratory failure. A total of 807 patients were included. Mortality was compared between the four following groups: RSV, COVID-19, seasonal influenza, and H1N1 groups. Patients in the RSV group had significantly more comorbidities than the other patients. At admission, patients in the COVID-19 group were significantly less severe than the others according to the simplified acute physiology score-2 (SAPS-II) and sepsis-related organ failure assessment (SOFA) scores. Using competing risk regression, COVID-19 (sHR = 1.61; 95% CI 1.10; 2.36) and H1N1 (sHR = 1.87; 95% CI 1.20; 2.93) were associated with a statistically significant higher mortality while seasonal influenza was not (sHR = 0.93; 95% CI 0.65; 1.31), when compared to RSV. Despite occurring in more severe patients, RSV and seasonal influenza group appear to be associated with a more favorable outcome than COVID-19 and H1N1 groups.

Improved 30-Day Survival Estimation in ICU Patients: A Comparative Analysis of Different Approaches With Real-World Data

OBJECTIVES

The objective of this study was to compare three different approaches for estimating 30-day survival in ICU studies, considering the issue of informative censoring that occurs when patients are lost to follow-up after discharge.

DESIGN

A comparative analysis was conducted to evaluate the effect of different approaches on the estimation of 30-day survival. Three methods were compared: the classical approach using the Kaplan-Meier (KM) estimator and Cox regression modeling, the competing risk approach using the Fine and gray model, considering censoring as a competing event, and the logistic regression approach.

SETTING

The study was conducted in a university ICU and data from patients admitted between 2010 and 2020 were included. Patient characteristics were collected from electronic records.

PATIENTS

A total of 10,581 patients were included in the study. The true date of death for each patient, obtained from a national registry, allowed for an absence of censoring.

INTERVENTIONS

All patients were censored at the time of discharge from the ICU, and the three different approaches were applied to estimate the mortality rate and the effects of covariates on mortality. Regression analyses were performed using five variables known to be associated with ICU mortality.

MEASUREMENTS AND MAIN RESULTS

The 30-day survival rate for the included patients was found to be 80.5% (95% CI, 79.7-81.2%). The KM estimator severely underestimated the 30-day survival (50.6%; 95% CI, 48.0-53.4%), while the competing risk and logistic regression approaches provided similar results, only slightly overestimating the survival rate (84.5%; 95% CI, 83.8-85.2%). Regression analyses showed that the estimates were not systematically biased, with the Cox and logistic regression models exhibiting greater bias compared with the competing risk regression method.

CONCLUSIONS

The competing risk approach provides more accurate estimates of 30-day survival and is less biased compared with the other methods evaluated.

Occurrences of post-traumatic stress disorder, anxiety, depression, and burnout syndrome in ICU staff workers after two-year of the COVID-19 pandemic: the international PSY-CO in ICU study

PURPOSE

The present study aimed at assessing the prevalences of post-traumatic stress disorder (PTSD) (main objective), anxiety, depression, and burnout syndrome (BOS) and their associated factors in intensive care unit (ICU) staff workers in the second year of the COVID-19 pandemic.

MATERIALS AND METHODS

An international cross-sectional multicenter ICU-based online survey was carried out among the ICU staff workers in 20 ICUs across 3 continents. ICUs staff workers (both caregivers and non-caregivers) were invited to complete PCL-5, HADS, and MBI questionnaires for assessing PTSD, anxiety, depression, and the different components of BOS, respectively. A personal questionnaire was used to isolate independent associated factors with these disorders.

RESULTS

PCL-5, HADS, and MBI questionnaires were completed by 585, 570, and 539 responders, respectively (525 completed all questionnaires). PTSD was diagnosed in 98/585 responders (16.8%). Changing familial environment, being a non-caregiver staff worker, having not being involved in a COVID-19 patient admission, having not been provided with COVID-19-related information were associated with PTSD. Anxiety was reported in 130/570 responders (22.8%). Working in a public hospital, being a woman, being financially impacted, being a non-clinical healthcare staff member, having no theoretical or practical training on individual preventive measures, and fear of managing COVID-19 patients were associated with anxiety. Depression was reported in 50/570 responders (8.8%). Comorbidity at risk of severe COVID-19, working in a public hospital, looking after a child, being a non-caregiver staff member, having no information, and a request for moving from the unit were associated with depression. Having received no information and no adequate training for COVID-19 patient management were associated with all 3 dimensions of BOS.

CONCLUSION

The present study confirmed that ICU staff workers, whether they treated COVID-19 patients or not, have a substantial prevalence of psychological disorders.

Occurrence of cardiovascular events in 168 cats with acute urinary tract obstruction

Background

Cardiovascular dysfunction associated with acute kidney injury has been recently described in veterinary medicine, but limited information is available for cats with urinary tract obstruction (UTO).

Objective

This retrospective study aimed to describe the type, frequency, timeline, and risk factors for cardiovascular events (CVEs) in cats treated for acute UTO.

Animals and procedures

Medical records of cats admitted to the intensive care unit for either upper (ureteral: UUTO) or lower (urethral: LUTO) UTO from 2016 to 2021 were reviewed. Cardiovascular events were defined as development of arrhythmia, heart murmur or gallop sound, clinical signs consistent with fluid overload (CRFO), or decreased tissue perfusion (DTP).

Results

One hundred and sixty-eight cats with UTO were recruited (56 with UUTO and 112 with LUTO). Cardiovascular events were reported in 61.9% of cases, including arrhythmia (33.6%), gallop rhythm (28.1%), heart murmur (15.3%), CRFO (14.4%), and DTP (8.6%). Potassium concentration, preexisting chronic kidney disease, and renal pelvic dilation at abdominal ultrasonography were associated with CVE occurrence in multivariate analysis.

Conclusions

This study highlighted frequent CVEs in cats treated for UTO, with a potential strong impact on outcome. Therefore, cardiovascular parameters of cats with preexisting chronic kidney disease or those admitted with hyperkalemia or renal pelvic dilation should be closely monitored.

Iron as an emerging therapeutic target in critically ill patients

The multiple roles of iron in the body have been known for decades, particularly its involvement in iron overload diseases such as hemochromatosis. More recently, compelling evidence has emerged regarding the critical role of non-transferrin bound iron (NTBI), also known as catalytic iron, in the care of critically ill patients in intensive care units (ICUs). These trace amounts of iron constitute a small percentage of the serum iron, yet they are heavily implicated in the exacerbation of diseases, primarily by catalyzing the formation of reactive oxygen species, which promote oxidative stress. Additionally, catalytic iron activates macrophages and facilitates the growth of pathogens. This review aims to shed light on this underappreciated phenomenon and explore the various common sources of NTBI in ICU patients, which lead to transient iron dysregulation during acute phases of disease. Iron serves as the linchpin of a vicious cycle in many ICU pathologies that are often multifactorial. The clinical evidence showing its detrimental impact on patient outcomes will be outlined in the major ICU pathologies. Finally, different therapeutic strategies will be reviewed, including the targeting of proteins involved in iron metabolism, conventional chelation therapy, and the combination of renal replacement therapy with chelation therapy.

Prognostic value of capillary refill time in adult patients: a systematic review with meta-analysis

PURPOSE

Acute circulatory failure leads to tissue hypoperfusion. Capillary refill time (CRT) has been widely studied, but its predictive value remains debated. We conducted a meta-analysis to assess the ability of CRT to predict death or adverse events in a context at risk or confirmed acute circulatory failure in adults.

METHOD

MEDLINE, EMBASE, and Google scholar databases were screened for relevant studies. The pooled area under the ROC curve (AUC ROC), sensitivity, specificity, threshold, and diagnostic odds ratio using a random-effects model were determined. The primary analysis was the ability of abnormal CRT to predict death in patients with acute circulatory failure. Secondary analysis included the ability of CRT to predict death or adverse events in patients at risk or with confirmed acute circulatory failure, the comparison with lactate, and the identification of explanatory factors associated with better accuracy.

RESULTS

A total of 60,656 patients in 23 studies were included. Concerning the primary analysis, the pooled AUC ROC of 13 studies was 0.66 (95%CI [0.59; 0.76]), and pooled sensitivity was 54% (95%CI [43; 64]). The pooled specificity was 72% (95%CI [55; 84]). The pooled diagnostic odds ratio was 3.4 (95%CI [1.4; 8.3]). Concerning the secondary analysis, the pooled AUC ROC of 23 studies was 0.69 (95%CI [0.65; 0.74]). The prognostic value of CRT compared to lactate was not significantly different. High-quality CRT was associated with a greater accuracy.

CONCLUSION

CRT poorly predicted death and adverse events in patients at risk or established acute circulatory failure. Its accuracy is greater when high-quality CRT measurement is performed.

Outcome and factors associated with mortality in patients receiving urgent chemotherapy in the ICU: A retrospective study

PURPOSE

This study aimed to assess the outcome and factors associated with mortality in patients who received urgent chemotherapy (CT) in the intensive care unit (ICU) in Lyon, France.

MATERIAL AND METHODS

A total of 147 adult patients diagnosed with cancer and requiring urgent CT during ICU stay between October 2014 and December 2019 were included in this retrospective study.

RESULTS

Hematological cancer was found in 77% of patients, and acute respiratory failure was the leading cause of ICU admission (46.3%). The 6-month mortality rate was 69.4%; patients with solid cancer had a higher risk of mortality. Patients who died within 6 months had a poor performance score and a higher SOFA score at admission. The multivariate analysis showed that solid tumors, sepsis on the day of CT, and SOFA score on the day of CT were associated with 6-month mortality. Additionally, 95% of patients who survived the ICU resumed conventional CT, with a higher likelihood of resuming CT among those with hematological cancer.

CONCLUSION

Urgent CT in the ICU is feasible in a specific subset of patients, mainly those with hematological cancer, with resumption of the curative treatment regimen after ICU discharge.

Use of high-flow oxygen therapy in a cat with cardiogenic pulmonary edema

Case summary

A 7-month-old female spayed domestic shorthair cat was presented for respiratory distress due to cardiogenic pulmonary edema. Despite initial treatment and oxygen delivery in an oxygen tent, the cat still showed signs of severe respiratory effort and oxygen saturation measured via pulse oximetry was below 85%. Because the owners declined mechanical ventilation, the cat was transitioned to high-flow oxygen therapy (HFOT). HFOT allowed significant improvement of the respiration parameters within 15 mins without causing clinical complications. The cat was briefly anaesthetised for the placement of the nasal cannula on initiation of HFOT, and the interface was well tolerated thereafter. The cat was transitioned to an oxygen cage after 16 h, weaned from oxygen 4 h later and was discharged after 3 days of hospitalisation. Long-term follow-up showed no abnormalities, and the leading hypothesis was transient myocardial thickening.

Relevance and novel information

The first use of HFOT in a dyspneic cat is described in this study. HFOT could be a life-saving option for cats with severe hypoxemia or do-not-intubate orders that fail to respond to conventional oxygen therapies.

Use of pupillometry for the evaluation of analgesia in dogs hospitalized in intensive care: A prospective study

A prospective study was performed on hospitalized conscious dogs. The objectives were: 1) to evaluate the feasibility and reliability of portable infrared pupillometry using a measure of photo light reflexes, 2) to identify parameters influencing measures, and 3) to compare parameters before and after the administration of analgesia. Twenty-nine dogs were included. Pupillometry was feasible by a single person. There was an excellent reliability for the evaluation of pupil diameter. There was poor to good reliability for the other parameters. There was an association between weight and mean pupil diameter (estimate = 0.1 mm, CI95 = [0.0; 0.1], P = 0.02), mean diameter variation (estimate = 0.2%, CI95 = [0.0; 0.4], P = 0.01), and mean velocity (estimate = 0.08 ms, CI95 = [0.03; 0.13], P = 0.002). Male dogs had a significantly larger mean pupil diameter than females (estimate = 1.3 mm, CI95 = [0.1; 2.5], P = 0.03). Independently of weight and sex, there was an association between mean pupil diameter and pain score: the higher the pain score, the lower the mean pupil diameter. There was a correlation between mean pupil diameter and morphine dose (ρ = -0.78, P = 0.0004). There was no significant difference in pupil diameter, velocity, and latency before and after analgesic administration. In conclusion, results do not support the use of PLR measurement by pupillometry as a pain assessment technique in hospitalized conscious dogs.

Use of 1,3-Beta-D-Glucan concentration in peritoneal fluid for the diagnosis of intra-abdominal Candidiasis in Critically-ill patients

Intra-Abdominal Candidiasis (IAC) is frequent and associated with high mortality in intensive care unit (ICU) patients. Antifungal treatments may be overused due to a lack of diagnostic tools to rule out IAC. Serum 1,3-Beta-D-Glucan (BDG) concentrations are used to diagnose Candida infections, its concentration in peritoneal fluid (PF) may help to confirm or invalidate the diagnosis of IAC. We performed a non-interventional, prospective, multicenter study, at the Hospices Civils de Lyon, France, in seven ICU located in three different hospitals from December 2017 to June 2018. IAC was defined as the isolation of Candida in a sample collected from the intra-abdominal cavity under sterile conditions in patients displaying clinical evidence of intra-abdominal infection. Among the 113 included patients, 135 PF samples corresponding to 135 intra-abdominal infection episodes were collected and BDG concentrations were assessed. IAC accounted for 28 (20.7%) of the intra-abdominal infections. Antifungals were administered empirically to 70 (61.9%) patients; among them, 23 (32.9%) had an IAC. The median [IQR] BDG value was significantly higher in IAC (8100 [3000;15000] pg/mL) than in non-IAC samples (1961 [332;10650] pg/mL). BDG concentrations were higher in PF with Fecaloid aspect and in case of positive bacterial culture. For a BDG threshold of 125 pg/mL, the negative predictive value to assess IAC was 100%. In conclusion, low BDG PF concentrations could be used to rule out IAC. https://clinicaltrials.gov/ct2/show/NCT03469401.

Tracheal stent aspergillosis occurring after aortic allograft of the trachea

BACKGROUND

Aspergillosis is a fungal infection with many clinical forms. Invasive aspergillosis is the most widely known severe manifestation, but other forms can need intensive care.

AIM

Our purpose is to report a case of tracheal aspergilloma and provide a review of the literature concerning endobronchial aspergillus.

METHOD

We report a case of tracheal aspergilloma causing tracheal obstruction in a patient admitted in the ICU for respiratory distress. The aspergilloma occurred in a tracheal stent implanted during tracheal allograft for tracheal cancer. A combination of local and systemic antifungal was used with successful result.

Nurse-to-Nurse Familiarity and Mortality in the Critically Ill. A Multicenter Observational Study

RATIONALE

Nurse-to-nurse familiarity at work should strengthen the components of team working and enhance its efficiency. However, its impact on patient outcomes in critical care remains poorly investigated.

OBJECTIVES

To explore the role of nurse-to-nurse familiarity on inpatient deaths during intensive care unit stay.

METHODS

Retrospective observational study in eight adult academic intensive care units between 01/01/2011 and 31/12/2016.

MEASUREMENTS AND MAIN RESULTS

Nurse-to-nurse familiarity was measured across day and night 12-hour daily shifts as the mean number of previous collaborations between each nursing team member during previous shifts within the given Intensive Care Unit (suboptimal if<50). Primary outcome was a shift with at least one inpatient death, excluding death of patients with a decision to forego life-sustaining therapy. A multiple modified Poisson regression was computed to identify the determinants of mortality per shift, taking into account intensive care unit, patients' characteristics, patient-to-nurse and patient-to-assistant nurse ratios, nurse experience length and workload. A total of 43,479 patients were admitted of whom 3,311 (8%) died. Adjusted model showed a lower risk of a shift with mortality when nurse-to-nurse familiarity increased in the shift (relative risk 0.90 [0.82-0.98] 95%confidence intervals per 10 shifts, p=0.012). Low nurse-to-nurse familiarity during the shift combined with suboptimal patient-to-nurse and assistant-nurse ratios (suboptimal if >2.5 and >4, respectively) were associated with increased risk of shift with mortality (1.84 [1.15-2.96], p<0.001).

CONCLUSIONS

Shifts with low nurse-to-nurse familiarity were associated with an increased risk of patient deaths.

A retrospective comparison of COVID-19 and seasonal influenza mortality and outcomes in the ICUs of a French university hospital

BACKGROUND

SARS-Cov-2 (COVID-19) has become a major worldwide health concern since its appearance in China at the end of 2019.

OBJECTIVE

To evaluate the intrinsic mortality and burden of COVID-19 and seasonal influenza pneumonia in ICUs in the city of Lyon, France.

DESIGN

A retrospective study.

SETTING

Six ICUs in a single institution in Lyon, France.

PATIENTS

Consecutive patients admitted to an ICU with SARS-CoV-2 pneumonia from 27 February to 4 April 2020 (COVID-19 group) and seasonal influenza pneumonia from 1 November 2015 to 30 April 2019 (influenza group). A total of 350 patients were included in the COVID-19 group (18 refused to consent) and 325 in the influenza group (one refused to consent). Diagnosis was confirmed by RT-PCR. Follow-up was completed on 1 April 2021.

MAIN OUTCOMES AND MEASURES

Differences in 90-day adjusted-mortality between the COVID-19 and influenza groups were evaluated using a multivariable Cox proportional hazards model.

RESULTS

COVID-19 patients were younger, mostly men and had a higher median BMI, and comorbidities, including immunosuppressive condition or respiratory history were less frequent. In univariate analysis, no significant differences were observed between the two groups regarding in-ICU mortality, 30, 60 and 90-day mortality. After Cox modelling adjusted on age, sex, BMI, cancer, sepsis-related organ failure assessment (SOFA) score, simplified acute physiology score SAPS II score, chronic obstructive pulmonary disease and myocardial infarction, the probability of death associated with COVID-19 was significantly higher in comparison to seasonal influenza [hazard ratio 1.57, 95% CI (1.14 to 2.17); P = 0.006]. The clinical course and morbidity profile of both groups was markedly different; COVID-19 patients had less severe illness at admission (SAPS II score, 37 [28 to 48] vs. 48 [39 to 61], P < 0.001 and SOFA score, 4 [2 to 8] vs. 8 [5 to 11], P < 0.001), but the disease was more severe considering ICU length of stay, duration of mechanical ventilation, PEEP level and prone positioning requirement.

CONCLUSION

After ICU admission, COVID-19 was associated with an increased risk of death compared with seasonal influenza. Patient characteristics, clinical course and morbidity profile of these diseases is markedly different.

Effect of GOAL-Directed ANalgesia using ANI (Analgesia/Nociception Index) during general anesthesia on immediate postoperative pain and intraoperative hemodynamics in adult patients (GOALDAN study): a study protocol for randomized, controlled, multicenter trial

Background

Severe postoperative pain remains a major problem that is seen in 20 to 40% of patients. The Analgesia/Nociception Index (ANI) is a 0–100 index reflecting the relative parasympathetic activity allowing for intraoperative analgesia monitoring. We have previously shown that an ANI value < 50 immediately before extubation may predict the occurrence of immediate postoperative pain with good performance. We hypothesized that GOAL-Directed ANalgesia may provide reduced immediate postoperative pain and optimized intraoperative remifentanil administration (GOLDAN study).

Methods

The GOALDAN study is an international, multicenter, simple-blind, parallel, prospective, randomized, controlled, two-armed trial. Patients are randomly assigned in a 1:1 ratio in the control group or in the experimental group. Patients will be randomly allocated to either the intervention group (ANI) or the control group (standard care only). In the ANI group, the administration of remifentanil will be goal-directed targeting a 50–80 ANI range, with a prophylactic injection of morphine immediately after extubation if the case of ANI < 50. Our primary objective was to determine whether the prophylactic administration of morphine at the end of the procedure in patients at risk of immediate postoperative pain (ANI < 50 immediately before extubation) could reduce the incidence of the latter by 50% in the post-anesthetic care unit. Our secondary objective was to determine whether the intraoperative use of goal-directed analgesia with an ANI target of 50 to 80 could improve intraoperative hemodynamics and postoperative outcome.

Discussion

Because of the paucity of well-conducted trials, the authors believe that a randomized-controlled trial will improve the evidence for using analgesia monitoring during general anesthesia and strengthen current recommendations for intraoperative analgesia management.

Trial registration

ClinicalTrials.gov NCT03618082. Registered on 7 August 2018

Intensive care-related loss of quality of life and autonomy at 6 months post-discharge: Does COVID-19 really make things worse?

Objective

To compare old patients hospitalized in ICU for respiratory distress due to COVID-19 with old patients hospitalized in ICU for a non-COVID-19-related reason in terms of autonomy and quality of life.

Design

Comparison of two prospective multi-centric studies.

Setting

This study was based on two prospective multi-centric studies, the Senior-COVID-Rea cohort (COVID-19-diagnosed ICU-admitted patients aged over 60) and the FRAGIREA cohort (ICU-admitted patients aged over 70).

Patients

We included herein the patients from both cohorts who had been evaluated at day 180 after admission (ADL score and quality of life).

Interventions

None.

Measurements and main results

A total of 93 COVID-19 patients and 185 control-ICU patients were included. Both groups were not balanced on age, body mass index, mechanical ventilation, length of ICU stay, and ADL and SAPS II scores. We modeled with ordered logistic regression the influence of COVID-19 on the quality of life and the ADL score. After adjustment on these factors, we observed COVID-19 patients were less likely to have a loss of usual activities (aOR [95% CI] 0.47 [0.23; 0.94]), a loss of mobility (aOR [95% CI] 0.30 [0.14; 0.63]), and a loss of ADL score (aOR [95% CI] 0.30 [0.14; 0.63]). On day 180, 52 (56%) COVID-19 patients presented signs of dyspnea, 37 (40%) still used analgesics, 17 (18%) used anxiolytics, and 14 (13%) used antidepressant.

Conclusions

COVID-19-related ICU stay was not associated with a lower quality of life or lower autonomy compared to non-COVID-19-related ICU stay.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03958-6.

Effects of methylene blue on microcirculatory alterations following cardiac surgery: A prospective cohort study

BACKGROUND

Methylene blue is used as rescue therapy to treat catecholamine-refractory vasoplegic syndrome after cardiac surgery. However, its microcirculatory effects remain poorly documented.

OBJECTIVE

We aimed to study microcirculatory abnormalities in refractory vasoplegic syndrome following cardiac surgery with cardiopulmonary bypass and assess the effects of methylene blue.

DESIGN

A prospective open-label cohort study.

SETTING

20-Bed ICU of a tertiary care hospital.

PATIENTS

25 Adult patients receiving 1.5 mg kg-1 of methylene blue intravenously for refractory vasoplegic syndrome (defined as norepinephrine requirement more than 0.5 μg kg-1 min-1) to maintain mean arterial pressure (MAP) more than 65 mmHg and cardiac index (CI) more than 2.0 l min-1 m-2.

MAIN OUTCOME MEASURES

Complete haemodynamic set of measurements at baseline and 1 h after the administration of methylene blue. Sublingual microcirculation was investigated by sidestream dark field imaging to obtain microvascular flow index (MFI), total vessel density, perfused vessel density and heterogeneity index. Microvascular reactivity was assessed by peripheral near-infrared (IR) spectroscopy combined with a vascular occlusion test. We also performed a standardised measurement of capillary refill time.

RESULTS

Despite normalised CI (2.6 [2.0 to 3.8] l min-1 m-2) and MAP (66 [55 to 76] mmHg), patients with refractory vasoplegic syndrome showed severe microcirculatory alterations (MFI < 2.6). After methylene blue infusion, MFI significantly increased from 2.0 [0.1 to 2.5] to 2.2 [0.2 to 2.8] (P = 0.008), as did total vessel density from 13.5 [8.3 to 18.5] to 14.9 [10.1 to 14.7] mm mm-2 (P = 0.02) and perfused vessel density density from 7.4 [0.1 to 11.5] to 9.1 [0 to 20.1] mm mm-2 (P = 0.02), but with wide individual variation. Microvascular reactivity assessed by tissue oxygen resaturation speed also increased from 0.5 [0.1 to 1.8] to 0.7 [0.1 to 2.7]% s-1 (P = 0.002). Capillary refill time remained unchanged throughout the study.

CONCLUSION

In refractory vasoplegic syndrome following cardiac surgery, we found microcirculatory alterations despite normalised CI and MAP. The administration of methylene blue could improve microvascular perfusion and reactivity, and partially restore the loss of haemodynamic coherence.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04250389.

Association between out-of-bed mobilization during the ICU stay of elderly patients and long-term autonomy: A cohort study

PURPOSE

Our objective was to estimate the impact of the absence of Out-of-Bed (OoB) mobilization during intensive care unit (ICU) stay among patients ≥70 years on their long-term autonomy.

METHODS

We conducted an ancillary study of the multicenter FRAGIREA study, including patients aged over 70 years, admitted to ICU for more than 48 h. We excluded the patients who died before day 180, who were lost to follow-up, and for whom the baseline autonomy (ADL) score was not available. Patients were classified into the OoB or non-OoB-mobilization group, and the impact of OoB mobilization on the decreased 6-month autonomy was estimated.

RESULTS

Among the 548 patients of the FRAGIREA cohort, 276 were included in the present study. Among them, 226 had OoB mobilization and 50 did not. 220/276 (80%) patients experienced the transfer to chair as rehabilitation therapy, passive mobilization and transfer to upright sitting were also frequently performed. A decrease in the 6-month autonomy was observed for 63 (23%) patients. After the elimination of potential confounders, non-OoB-mobilization patients had a greater risk of 6-month decreased autonomy (aOR 2.43 [1.18; 4.98]).

CONCLUSIONS

Mobilization during the ICU stay of elderly ICU patient survivors was associated with a lower decreased autonomy at 6 months.

French multicentre observational study on SARS-CoV-2 infections intensive care initial management: the FRENCH CORONA study

AIM

Describing acute respiratory distress syndrome patterns, therapeutics management, and outcomes of ICU COVID-19 patients and indentifying risk factors of 28-day mortality.

METHODS

Prospective multicentre, cohort study conducted in 29 French ICUs. Baseline characteristics, comorbidities, adjunctive therapies, ventilatory support at ICU admission and survival data were collected.

RESULTS

From March to July 2020, 966 patients were enrolled with a median age of 66 (interquartile range 58-73) years and a median SAPS II of 37 (29-48). During the first 24 h of ICU admission, COVID-19 patients received one of the following respiratory supports: mechanical ventilation for 559 (58%), standard oxygen therapy for 228 (24%) and high-flow nasal cannula (HFNC) for 179 (19%) patients. Overall, 721 (75%) patients were mechanically ventilated during their ICU stay. Prone positioning and neuromuscular blocking agents were used in 494 (51%) and 460 (48%) patients, respectively. Bacterial co-infections and ventilator-associated pneumonia were diagnosed in 79 (3%) and 411 (43%) patients, respectively. The overall 28-day mortality was 18%. Age, pre-existing comorbidities, severity of respiratory failure and the absence of antiviral therapy on admission were identified as independent predictors of 28-day outcome.

CONCLUSION

Severity of hypoxaemia on admission, older age (> 70 years), cardiovascular and renal comorbidities were associated with worse outcome in COVID-19 patients. Antiviral treatment on admission was identified as a protective factor for 28-day mortality. Ascertaining the outcomes of critically ill COVID-19 patients is crucial to optimise hospital and ICU resources and provide the appropriate intensity level of care.

Associations between peripheral perfusion disorders, mean arterial pressure and dose of norepinephrine administrated in the early phase of septic shock

The aim of the study was to explore the correlations between peripheral perfusion, mean arterial pressure and the dose-rate of norepinephrine (NE) infused for the treatment of septic shock. The study is retrospective analysis of data acquired prospectively on 57 patients during the first 24 hours after the occurrence of the shock. Clinical and haemodynamic characteristics, skin perfusion parameters (capillary refill time [CRT], mottling score and temperature gradients) and the dose rate of NE infusion were collected. Negative correlations between mean arterial pressure (MAP) and temperature gradients (core-to-toe: P = .03, core-to-index: P = .04) were found and abnormal CRT was associated with lower MAP (P = .02). The dose rate of NE was negatively correlated with temperature gradients (core-to-toe: P = .02, core-to-index: P = .01, forearm-to-index: P = .008) in the overall population. In patients receiving NE for at least 12 hours, the NE dose rate positively was correlated with the mottling score (P = .006), temperature gradients (core-to-toe: P = .04, forearm-to-index: P = .02, core-to-index: P = .005) and CRT (P = .001). The dose of NE administrated was associated with 14-days mortality (odds ration [OR] = 1.21 [1.06-1.38], P = .006) and with 28-days mortality (OR = 1.17 [1.01-1.36], P = 0.04). In conclusion, the study described the presence of correlations between peripheral perfusion and MAP and between peripheral perfusion and the dose rate of NE infusion.

Performance of the Parasympathetic Tone Activity (PTA) index to predict changes in mean arterial pressure in anaesthetized horses with different health conditions

The parasympathetic tone activity (PTA) index is based on heart rate variability and has been developed recently in animals to assess their relative parasympathetic tone. This study aimed to evaluate PTA index in anaesthetized horses with different health conditions and the performance of PTA variations (∆PTA) to predict changes in mean arterial pressure (MAP). Thirty-nine client-horses were anaesthetized for elective or colic surgery and divided into "Elective" and "Colic" groups. During anaesthesia, dobutamine was administered as treatment of hypotension (MAP <60 mmHg). In both groups, no significant variation of PTA and MAP were detected immediately before and after cutaneous incision. The PTA index increased 5 min before each hypotension, whereas it decreased 1 min after dobutamine administration. Horses of the Colic group had lower PTA values than those of the Elective group, whereas MAP did not differ between groups. To predict a 10% decrease in MAP, ΔPTA performance was associated with: AUC ROC [95% CI] =0.80 [0.73 to 0.85] (p < 0.0001), with a sensitivity of 62.5% and a specificity of 94.6% for a threshold value of 25%. The PTA index in anaesthetized horses appears to be influenced by the health condition. The shift toward lower PTA values in colic horses may reflect a sympathetic predominance. An increase in PTA of >25% in 1 min showed an acceptable performance to predict MAP decrease of >10% within 5 min. Even though these results require further evaluation, this index may thus help to predict potential autonomic dysfunctions in sick animals.

Evaluation of the sublingual microcirculation with sidestream dark field video microscopy in horses anesthetized for an elective procedure or intestinal surgery

OBJECTIVE

To compare the sublingual microcirculation between healthy horses anesthetized for elective procedures and horses with colic anesthetized for abdominal surgery and to determine the effect of mean arterial blood pressure (MAP) on the microcirculation.

ANIMALS

9 horses in the elective group and 8 horses in the colic group.

PROCEDURES

Sublingual microcirculation was assessed with sidestream dark field video microscopy. Videos were captured at 3 time points during anesthesia. Recorded microvasculature parameters were De Backer score (DBS), total density of perfused vessels (PVD) and small vessels (PVD-S), total proportion of perfused vessels (PPV) and small vessels (PPV-S), vascular flow index (MFI), and heterogeneity index (HI). Blood pressure during hypotensive (MAP < 60 mm Hg) and normotensive (MAP ≥ 60 mm Hg) episodes was also recorded.

RESULTS

During normotensive episodes, the elective group had significantly better PPV and PPV-S versus the colic group (median PPV, 76% vs 50%; median PPV-S, 73% vs 51%). In both groups, PPV decreased during anesthesia (elective group, -29%; colic group, -16%) but significantly improved in the elective group 15 minutes before the end of anesthesia (59%). During hypotensive episodes, PVD-S was better preserved in the colic group (11.1 vs 3.8 mm/mm²). No differences were identified for the microcirculatory parameters between normo- and hypotensive episodes in the colic group.

CONCLUSIONS AND CLINICAL RELEVANCE

Sublingual microcirculation was better preserved in healthy horses anesthetized for elective procedures than in horses with colic anesthetized for abdominal surgery despite resuscitation maneuvers. Results indicated that the macrocirculation and microcirculation in critically ill horses may be independent.

Septic thrombophlebitis with persistent bacteraemia treated by thrombolysis

Septic thrombophlebitis requires both adapted antimicrobial therapy and control of the source of the infection. The source of the infection is generally controlled through adequate management of anticoagulation. In this study, we present the case of a 50 years old woman, with septic thrombophlebitis of a peripherally inserted central catheters line and with persistent bacteremia and thrombus, where in situ thrombolysis has successfully removed the thrombus.

Effectiveness of chest physiotherapy using passive slow expiratory techniques in dogs with airway fluid accumulation: A randomized controlled trial

BACKGROUND

Prolonged slow expiration (PSE) and assisted cough (AC) are airway clearance techniques feasible and well tolerated in dogs.

OBJECTIVES

To evaluate the effectiveness of PSE and AC as chest physiotherapy (CP) techniques in dogs with airway fluid accumulation.

ANIMALS

Thirty-one client-owned dogs hospitalized in an intensive care unit from October 2014 to May 2018.

METHODS

Prospective randomized controlled trial. Dogs presented with or developing acute dyspnea during hospitalization associated with airway fluid accumulation were assigned to CP group (medical treatment and CP, 15 dogs) or control group (medical treatment alone, 16 dogs). The arterial partial pressure of oxygen (PaO2 ) to fraction of inspired oxygen (FiO2 ) ratio (P/F ratio; PaO2 /FiO2 × 100) was calculated daily for the 1st 48 hours of hospitalization and using the last arterial blood gas performed before discharge or death. The ratio of days of hospitalization with oxygen/total number of hospitalization days (ratio of oxygen-free-days [O2 Free]) was calculated.

RESULTS

During the 1st 48 hours, the P/F ratio increased significantly in the CP group compared to the control group (+ 35.1 mm Hg/day; 95% confidence interval [CI] = 0.4-57.5; P = .03). The (median; 1st quartile to 3rd quartile) difference between the P/F ratio at discharge and inclusion was significantly higher in the CP group (178 mm Hg; 123-241) than in the control group (54 mm Hg; -19 - 109; P = .001). Mean O2 Free increased by 46.4% in the CP group compared with control group (95% CI = 16-59; P = .001). Mortality was 13% (2/15) in the CP group and 44% (7/16) in the control group (P = .07).

CONCLUSIONS AND CLINICAL IMPORTANCE

Prolonged slow expiration and AC improved P/F ratio within 48 hours and decreased need for oxygenation in dyspneic dogs with acute airway fluid accumulation.

Can Thoracic Ultrasound on Admission Predict the Outcome of Critically Ill Patients with SARS-CoV-2? A French Multi-Centric Ancillary Retrospective Study

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have led to massive admissions to intensive care units (ICUs). An ultrasound examination of the thorax is widely performed on admission in these patients. The primary objective of our study was to assess the performance of the lung ultrasound score (LUS) on ICU admission to predict the 28-day mortality rate in patients with SARS-CoV-2. The secondary objective was to asses the performance of thoracic ultrasound and biological markers of cardiac injury to predict mortality.

Methods

This multicentre, retrospective, observational study was conducted in six ICUs of four university hospitals in France from 15 March to 3 May 2020. Patients admitted to ICUs because of SARS-CoV-2-related acute respiratory failure and those who received an LUS examination at admission were included. The area under the receiver-operating characteristics (ROC) curve was determined for the LUS score to predict the 28-day mortality rate. The same analysis was performed for the Simplified Acute Physiology Score, left ventricular ejection fraction, cardiac output, brain natriuretic peptide and ultra-sensitive troponin levels at admission.

Results

In 57 patients, the 28-day mortality rate was 21%. The area under the ROC curve of the LUS score value on ICU admission was 0.68 [95% CI 0.54–0.82; p = 0.05]. In non-intubated patients on ICU admission (n = 40), the area under the ROC curves was 0.84 [95% CI 0.70–0.97; p = 0.005]. The best cut-off of 22 corresponded to 85% specificity and 83% sensitivity.

Conclusions

LUS scores on ICU admission for SARS-CoV-2 did not efficiently predict the 28-day mortality rate. Performance was better for non-intubated patients at admission. Performance of biological cardiac markers may be equivalent to the LUS score.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01702-0.

[Intensive Care Nurses, Psychological Disorders and COVID-19. The COVID IMPACT NATIONAL STUDY]

La pandémie de la COVID-19 a mis les établissements hospitaliers sous tension. L’objectif de cette étude nationale est de déterminer la prévalence des troubles psychologiques dans le personnel soignant infirmier de réanimation. Nous avons élaboré un questionnaire électronique diffusé par mail entre le 17 juin et le 17 juillet 2020. Trois cent quatre vingt un professionnels exerçants en réanimation au moment de la pandémie (infirmiers de réanimation, infirmiers anesthésistes, infirmiers de bloc opératoire et cadres de santé) y ont répondu. L’Hospital Anxiety and Depression Scale et l’Impact Event Scale Revisited ont été utilisées pour évaluer la prévalence de l’anxiété, de la dépression et du stress post-traumatique dans cette population. Les Infirmièr(e)s de bloc opératoire exerçant en réanimation sont celles qui ont le plus souffert de troubles psychologiques : trouble anxieux (64 %) (p = 0,055), trouble dépressif (45 %) (p = 0,004) et stress post-traumatique (45 %) (p = 0,008). Les infirmier(e)s travaillant habituellement en réanimation étaient les moins touchés : trouble anxieux (30 %), trouble dépressif (11 %) et stress post-traumatique (20 %). Les facteurs de risque de développer un trouble psychologique étaient le faible niveau de formation en réanimation, le fait d’exercer en réanimation contre son gré et d’avoir des antécédents de burn out. Cette étude permet d’établir un profil de professionnel à risque de développer des troubles psychologiques dans le contexte actuel. Les solutions envisageables sont de former le personnel et de proposer une prise en charge psychologique accessible et individualisée.

Impact of flow and temperature on non-dyspnoeic dogs' tolerance undergoing high-flow oxygen therapy

OBJECTIVES

To prospectively describe the impact of gas flow rate and temperature on dog's tolerance of high-flow nasal oxygen therapy during recovery from anaesthesia, hypothesizing that higher flow rates and temperatures will decrease tolerance.

MATERIALS AND METHODS

Twelve non-dyspnoeic client-owned dogs recovering from general anaesthesia were included in this study. After extubation, a nasal cannula was positioned and high-flow nasal oxygen therapy was initiated. Two flow rates (two or four time the theoretical minute ventilation: HF2 and HF4), each of them combined with two temperatures (31 and 37°C: T31 and T37), were randomly applied (four conditions per dog). For each condition, cardiovascular and respiratory parameters (heart rate, respiratory rate, systolic arterial blood pressure and pulse oximeter oxygen saturation), sedation score and tolerance score were recorded at initiation (T₀ ) and after 10 minutes of accommodation (T₁₀ ).

RESULTS

Sedation scores were not significantly different between the four conditions. Cardiovascular and respiratory parameters were not significantly different between any condition at both T₀ and T₁₀ . Tolerance scores were good and not significantly different between any flow rate or temperature (HF2-T31: 4 (2-4), HF4-T31: 4 (2-4), HF2-T37: 4 (2-4), HF4-T37: 4 (1-4)).

CLINICAL SIGNIFICANCE

The gas flow rates and temperatures studied have no impact on tolerance during the recovery period of non-dyspnoeic dogs, and high-flow nasal cannula is well tolerated. Further studies are required to confirm these results in dyspnoeic dogs.

Spontaneous rupture of an aneurysm of the superior thyroid artery: A rare cause of acute respiratory failure

Ruptured aneurysm of superior thyroid artery is a very rare pathological event. Underlying causes such as trauma, malignancy or iatrogenic are not systematically found. Resulting cervical hematoma is life threatening and can lead to acute respiratory failure, dysphagia, vocal cord paralysis and hemomediastinum. Endovascular treatment combined with surgical drainage has been described as an effective treatment. In this case report, a 63-year-old man presented a spontaneous rupture of an aneurysm of superior thyroid artery resulting in cervical hematoma and acute respiratory failure.

[Involving families in intensive care]

The place of families in intensive care is still too often underestimated. However, the involvement of family members would have multiple benefits for patients, but also for those around them. Family participation is a promising concept that needs to be studied on the ground and on a large scale, in order to prove itself and guide health professionals in their daily practice.

PIPAC versus HIPEC: cisplatin spatial distribution and diffusion in a swine model

Purpose: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel approach for delivering intraperitoneal chemotherapy and offers perspective in the treatment of peritoneal carcinomatosis. Concept is based on a 12 mmHg capnoperitoneum loaded with drug changed in microdoplets. It was postulated to guarantee a more homogeneous drug distribution and tissular uptake than hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study was to compare cisplatin peritoneal distribution and pharmacokinetic between HIPEC and PIPAC procedures in a healthy swine model.Methods: Two groups of eight pigs underwent either HIPEC with cisplatin (70 mg/m²) at 43 °C for 60 min, or PIPAC with cisplatin (7.5 mg/m²) for 30 min. Postoperatively, peritoneal areas were biopsied allowing peritoneal cavity cartography. Tissular and plasmatic cisplatin concentrations were analyzed.Results: Cisplatin distribution was heterogeneous in both the groups with higher concentrations obtained closed to the delivery sites. Median total platinum peritoneal concentration by pig was higher in the HIPEC group than in the PIPAC group (18.0 μg/g versus 4.3 μg/g, p < .001) but the yield was 2.2 times better with PIPAC. Platinum concentrations were higher in the HIPEC group in all stations. At each time-point, cisplatin plasmatic concentrations were higher in the HIPEC group (p < .001) but beneath the toxicity threshold.Conclusions: With doses used in clinical practice, HIPEC guaranteed a higher cisplatin peritoneal uptake than PIPAC in this swine model. Spatial drug distribution was heterogeneous with both technics, with hotspots closed to the drug delivery sites. Nevertheless, considering the dose ratio, IP drug uptake yield was better with PIPAC.