Tracheotomy in the intensive care unit: Guidelines from a French expert panel: The French Intensive Care Society and the French Society of Anaesthesia and Intensive Care Medicine

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the grading of recommendations assessment, development and evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1±) and 6 a low level of proof (Grade 2±). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation

Background

Despite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation.

Methods

ECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006–2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted.

Results

Seventeen high-risk PE patients [median age 51 (range 18–70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45–95)] were placed on VA-ECMO for 4 (1–12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0–106) mmHg, 6.99 (6.54–7.37) and 13 (4–19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4–69) months post-ICU discharge.

Conclusions

VA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1655-8) contains supplementary material, which is available to authorized users.

Extracorporeal membrane oxygenation for pheochromocytoma-induced cardiogenic shock

BACKGROUND

Pheochromocytoma, a rare catecholamine-producing tumor, might provoke stress-induced Takotsubo-like cardiomyopathy and severe cardiogenic shock. Because venoarterial-extracorporeal membrane oxygenation (VA-ECMO) rescue of pheochromocytoma-induced refractory cardiogenic shock has rarely been reported, we reviewed our ICU patients' presentations and outcomes.

METHODS

All pheochromocytoma-induced refractory cardiogenic shock cases managed with VA-ECMO (January 2007-March 2015) were prospectively included and reviewed. We also performed a systematic review on this topic.

RESULTS

Nine patients (7 women, 2 men; 31-51 [median, 43 (IQR 36-49) years old]) were included; none had a previously known pheochromocytoma. Six of them had medical histories suggestive of the diagnosis: palpitations and headaches for several months for four, multiple endocrine neoplasia syndrome type 1 for one and recurrent Takotsubo disease for one; at hospital admission, all were hypertensive despite cardiogenic shock. Three others had an identified surgical triggering factor. All nine patients rapidly developed refractory cardiogenic shock with very severe left ventricular (LV) impairment (LV ejection-fraction range 5-20%; LV outflow-tract velocity-time integral range 3-8 cm). Seven patients' abdominal computed tomography scans showed pheochromocytoma-suggestive adrenal gland tumors (no scan during ICU stay for 2). Despite VA-ECMO implantation, three patients died of refractory multiple organ failure. For the six others, myocardial function improved and ECMO was removed 3-7 days post-implantation; α- and β-blockers were progressively introduced. Five survivors underwent pheochromocytoma excision 3 weeks-4 months post-ICU discharge, with satisfactory outcomes. One patient, whose pheochromocytoma was diagnosed 1 year after the index event, underwent uneventful surgical adrenalectomy. Systematic review retrieved 40 cases of pheochromocytoma-induced cardiogenic shock requiring mechanical support (mostly ECMO), with a mortality rate of 7%. Pheochromocytoma was removed surgically after mechanical support weaning in 31 patients and during mechanical support in 5. Four were not operated.

CONCLUSIONS

Pheochromocytoma is a rare but reversible cause of cardiogenic shock amenable to VA-ECMO rescue. Adrenal gland imaging should be obtained for all patients with unexplained cardiogenic shock. Lastly, it might be safer to perform adrenalectomy several weeks after the initial catastrophic presentation, once recovery of LV systolic function is complete.

Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure: The EMPIRICUS Randomized Clinical Trial

IMPORTANCE

Although frequently used in treating intensive care unit (ICU) patients with sepsis, empirical antifungal therapy, initiated for suspected fungal infection, has not been shown to improve outcome.

OBJECTIVE

To determine whether empirical micafungin reduces invasive fungal infection (IFI)-free survival at day 28.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter double-blind placebo-controlled study of 260 nonneutropenic, nontransplanted, critically ill patients with ICU-acquired sepsis, multiple Candida colonization, multiple organ failure, exposed to broad-spectrum antibacterial agents, and enrolled between July 2012 and February 2015 in 19 French ICUs.

INTERVENTIONS

Empirical treatment with micafungin (100 mg, once daily, for 14 days) (n = 131) vs placebo (n = 129).

MAIN OUTCOMES AND MEASURES

The primary end point was survival without proven IFI 28 days after randomization. Key secondary end points included new proven fungal infections, survival at day 28 and day 90, organ failure, serum (1-3)-β-D-glucan level evolution, and incidence of ventilator-associated bacterial pneumonia.

RESULTS

Among 260 patients (mean age 63 years; 91 [35%] women), 251 (128, micafungin group; 123, placebo group) were included in the modified intent-to-treat analysis. Median values were 8 for Sequential Organ Failure Assessment (SOFA) score, 3 for number of Candida-colonized sites, and 99 pg/mL for level of (1-3)-β-D-glucan. On day 28, there were 82 (68%) patients in the micafungin group vs 79 (60.2%) in the placebo group who were alive and IFI free (hazard ratio [HR], 1.35 [95% CI, 0.87-2.08]). Results were similar among patients with a (1-3)-β-D-glucan level of greater than 80 pg/mL (n = 175; HR, 1.41 [95% CI, 0.85-2.33]). Day-28 IFI-free survival in patients with a high SOFA score (>8) was not significantly different when compared between the micafungin vs placebo groups (HR, 1.69 [95% CI, 0.96-2.94]). Use of empirical micafungin decreased the rate of new invasive fungal infection in 4 of 128 patients (3%) in the micafungin group vs placebo (15/123 patients [12%]) (P = .008).

CONCLUSIONS AND RELEVANCE

Among nonneutropenic critically ill patients with ICU-acquired sepsis, Candida species colonization at multiple sites, and multiple organ failure, empirical treatment with micafungin, compared with placebo, did not increase fungal infection-free survival at day 28.

TRIAL REGISTRATION

clinicaltrials.gov Idenitfier: NCT01773876.

Venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock post-cardiac arrest

PURPOSE

To describe the characteristics, outcomes, and risk factors associated with poor outcome of venoarterial extracorporeal membrane oxygenation (VA-ECMO)-treated patients with refractory shock post-cardiac arrest.

METHODS

We retrospectively analyzed data collected prospectively (March 2007-January 2015) in a 26-bed tertiary hospital intensive care unit. All patients implanted with VA-ECMO for refractory cardiogenic shock after successful resuscitation from cardiac arrest were included. Refractory cardiac arrest patients, given VA-ECMO under cardiopulmonary resuscitation, were excluded.

RESULTS

Ninety-four patients received VA-ECMO for refractory shock post-cardiac arrest. Their hospital and 12-month survival rates were 28 and 27 %, respectively. All 1-year survivors were cerebral performance category 1. Multivariable analysis retained INR >2.4 (OR 4.9; 95 % CI 1.4-17.2), admission SOFA score >14 (OR 5.3; 95 % CI 1.7-16.5), and shockable rhythm (OR 0.3; 95 % CI 0.1-0.9) as independent predictors of hospital mortality, but not SAPS II, out-of-hospital cardiac arrest score, or other cardiac arrest variables. Only 10 % of patients with an admission SOFA score >14 survived, whereas 50 % of those with scores ≤14 were alive at 1 year. Restricting the analysis to the 67 patients with out-of-hospital cardiac arrest of coronary cause yielded similar results.

CONCLUSION

Among 94 patients implanted with VA-ECMO for refractory cardiogenic shock post-cardiac arrest resuscitation, the 24 (27 %) 1-year survivors had good neurological outcomes, but survival was significantly better for patients with admission SOFA scores <14, shockable rhythm, and INR ≤2.4. VA-ECMO might be considered a rescue therapy for patients with refractory cardiogenic shock post-cardiac arrest resuscitation.

Brain injury during venovenous extracorporeal membrane oxygenation

PURPOSE

The frequency of neurological events and their impact on patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) are unknown. We therefore study the epidemiology, risk factors, and impact of cerebral complications occurring in VV-ECMO patients.

METHODS

Observational study conducted in a tertiary referral center (2006-2012) on patients developing a neurological complication (ischemic stroke or intracranial bleeding) while on VV-ECMO versus those who did not, and a systematic review on this topic.

RESULTS

Among 135 consecutive patients who had received VV-ECMO, 18 (15 assessable) developed cerebral complications on ECMO: cerebral bleeding in 10 (7.5 %), ischemic stroke in 3 (2 %), or diffuse microbleeds in 2 (2 %), occurring after respective medians (IQR) of 3 (1-11), 21 (10-26), and 36 (8-63) days post-ECMO onset. Intracranial bleeding was independently associated with renal failure at intensive care unit admission and rapid PaCO2 decrease at ECMO initiation, but not with age, comorbidities, or hemostasis disorders. Seven (70 %) patients with intracranial bleeding and one (33 %) with ischemic stroke died versus 40 % of patients without neurological event. A systematic review found comparable intracranial bleeding rates (5 %).

CONCLUSIONS

Neurological events occurred frequently in patients on VV-ECMO. Intracranial bleeding, the most frequent, occurred early and was associated with higher mortality. Because it was independently associated with rapid hypercapnia decrease, the latter should be avoided at ECMO onset, but its exact role remains to be determined. These findings may have major implications for the care of patients requiring VV-ECMO.

Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study

RATIONALE

Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence.

OBJECTIVES

To determine whether early HVHF decreases all-cause mortality 30 days after randomization.

METHODS

This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury.

MEASUREMENTS AND MAIN RESULTS

On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia.

CONCLUSIONS

For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

Could the DiversiLab® semi-automated repetitive-sequence-based PCR be an acceptable technique for typing isolates ofPseudomonas aeruginosa? An answer from our experience and a review of the literature

Recently the DiversiLab® (DL) system (bioMérieux) was developed as an automated platform that uses repetitive element polymerase chain reaction (rep-PCR) technology for standardized, reproducible DNA fingerprinting of bacteria. The purpose of this study was to evaluate the usefulness of DL rep-PCR for typing Pseudomonas aeruginosa isolates. The performance of DL rep-PCR was compared with that of pulsed-field gel electrophoresis (PFGE) in a prospective multicenter study of patients with ventilator-associated pneumonia due to P. aeruginosa, conducted in 3 intensive care units over a 31-month period. In total, 203 P. aeruginosa isolates from 66 patients, from whom at least 2 consecutive respiratory samples each were collected more than 48 h apart, were typed using DL rep-PCR. Forty isolates (corresponding to 20 patients) were also typed using PFGE of SpeI-digested DNA. The typeability was 100% with DL rep-PCR and 95% with PFGE. The discriminatory power was close for DL rep-PCR and for PFGE (Simpson’s diversity indices of 0.901 and 0.947, respectively). Insufficient agreement between DL rep-PCR and PFGE typing results was observed for the 40 selected isolates (adjusted Rand coefficient of 0.419), mostly due to isolates of the same DL rep-PCR type but of different PFGE types (adjusted Wallace coefficients of 0.306 for DL rep-PCR with PFGE, and of 0.667 for PFGE with DL rep-PCR). Considered together with published data, DL rep-PCR results should be interpreted with caution for the investigation of outbreaks caused by P. aeruginosa and evaluated in conjunction with epidemiological data.

Diagnostic value of ⁹⁹mTc-HMPAO-labeled leukocytes scintigraphy in suspicion of post-sternotomy mediastinitis relapse

BACKGROUND

The diagnostic value of radiolabeled white blood cells (WBCs) scintigraphy in mediastinitis is well established, but data in the specific context of relapse are lacking. The present study aimed at evaluation of the diagnostic value of WBCs scintigraphy in suspicion of mediastinitis relapse after prior surgical revision.

METHODS AND RESULTS

Multiple planar incidences of the chest were acquired 4 and 20 hours after injection of labeled WBC in 43 patients. In case of non-conclusive scintigraphy, a second scan was performed 2-3 weeks after the first one. The diagnosis of infection was based on positive bacteriological results; otherwise patients were followed up for at least 1 year. Out of 39 analyzable patients, 17 (44%) were diagnosed with mediastinitis relapse. After the first scan, 32 of 39 were correctly classified, 2 were false positive, and 5 were not conclusive. After completion of an additional scan in the latter 5 patients, 36 of 39 were correctly classified and 3 were false positive (100% sensitivity, 86% specificity, 85% positive predictive value, and 100% negative predictive value).

CONCLUSIONS

In the specific context of suspicion of mediastinitis relapse, the optimal diagnostic value was achieved by repeating the scan when the first one was not conclusive. In this context, a negative WBC scintigraphy was able to rule out infection, with potential major impact on therapeutic management in patients with poor clinical status.

Antibiotic stewardship in the intensive care unit

The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.

Delivering antibiotics to the lungs of patients with ventilator-associated pneumonia: an update

Ventilator-associated pneumonia is a serious hospital-acquired infection, with 20-70% crude mortality and 10-40% estimated attributable mortality. Insufficient antibiotic concentrations at the infection site when these drugs are given intravenously may lead to poor outcomes, particularly when difficult-to-treat pathogens are responsible; for example, Pseudomonas aeruginosa, extended spectrum beta lactamase-producing Gram-negative bacilli, Acinetobacter spp. and/or methicillin-resistant Staphylococcus aureus. Direct drug delivery to the infection site via aerosolization combined with intravenous administration achieves concentrations exceeding MICs of the pathogens, even those with impaired susceptibility. Experimental and recent clinical results demonstrated our markedly improved ability to deliver aerosolized antibiotics to the lung with new-generation devices, for example, vibrating-mesh nebulizers. Convincing clinical data from a large randomized trial are still lacking to support the routine administration of aerosolized antibiotics to treat ventilator-associated pneumonia, even though some small-randomized trials' observations are encouraging.

Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis

AIMS

To assess long-term outcomes and the management of critical left-sided infective endocarditis (IE) and evaluate the impact of surgery.

METHODS AND RESULTS

Among the 198 patients included prospectively for IE across 33 adult intensive care units (ICU) in France from 1 April 2007 to 1 October 2008, 137 (69%) were dead at a median follow-up time of 59.5 months. Characteristics significantly associated with mortality were: Sepsis-related Organ-Failure Assessment (SOFA) score at ICU admission [Hazard ratio (HR), 95% Confidence Interval (CI) of 1.43 (0.79-2.59) for SOFA 5-9; 2.01 (1.05-3.85) for SOFA 10-14; 3.53 (1.75-7.11) for SOFA 15-20; reference category SOFA 0-4; P = 0.003]; prosthetic mechanical valve IE [HR 2.01; 95% CI 1.09-3.69, P = 0.025]; vegetation size ≥15 mm [HR 1.64; 95% CI 1.03-2.63, P = 0.038]; and cardiac surgery [HR (95%CI), 0.33 (0.16-0.67) for surgery ≤1 day after IE diagnosis; 0.61 (0.29-1.26) for surgery 2-7 days after IE diagnosis; 0.42 (0.21-0.83) for surgery >7 days after IE diagnosis; reference category no surgery; P = 0.005]. One hundred and three (52%) patients underwent cardiac surgery after a median time of 6 (16) days. Independent predictors of surgical intervention on multivariate analysis were: age ≤60 years [Odds ratio (OR) 5.30; 95% CI (2.46-11.41), P < 0.01], heart failure [OR 3.27; 95% CI (1.03-10.35), P = 0.04], cardiogenic shock [OR 3.31; 95% CI (1.47-7.46), P = 0.004], septic shock [OR 0.25; 95% CI (0.11-0.59), P = 0.002], immunosuppression [OR 0.15; 95% CI (0.04-0.55), P = 0.004], and diagnosis before or within 24 h of ICU admission [OR 2.81; 95% CI (1.14-6.95), P = 0.025]. SOFA score calculated the day of surgery was the only independently associated factor with long-term mortality [HR (95% CI) 1.59 (0.77-3.28) for SOFA 5-9; 3.56 (1.71-7.38) for SOFA 10-14; 11.58 (4.02-33.35) for SOFA 15-20; reference category SOFA 0-4; P < 0.0001]. Surgical timing was not associated with post-operative outcomes. Of the 158 patients with a theoretical indication for surgery, the 58 deemed not fit had a 95% mortality rate.

CONCLUSION

Mortality in patients with critical IE remains unacceptably high. Factors associated with long-term outcomes are the severity of multiorgan failure, prosthetic mechanical valve IE, vegetation size ≥15 mm, and surgical treatment. Up to one-third of potential candidates do not undergo surgery and these patients experience extremely high mortality rates. The strongest independent predictor of post-operative mortality is the pre-operative multiorgan failure score while surgical timing does not seem to impact on outcomes.

The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome

Purpose

This study was designed to identify factors associated with death by 6 months post-intensive care unit (ICU) discharge and to develop a practical mortality risk score for extracorporeal membrane oxygenation (ECMO)-treated acute respiratory distress syndrome (ARDS) patients. We also assessed long-term survivors’ health-related quality of life (HRQL), respiratory symptoms, and anxiety, depression and post-traumatic stress disorder (PTSD) frequencies.

Methods

Data from 140 ECMO-treated ARDS patients admitted to three French ICUs (2008–2012) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQL, psychological and PTSD status.

Results

Main ARDS etiologies were bacterial (45 %), influenza A[H₁N₁] (26 %) and post-operative (17 %) pneumonias. Six months post-ICU discharge, 84 (60 %) patients were still alive. Based on multivariable logistic regression analysis, the PRESERVE (PRedicting dEath for SEvere ARDS on VV-ECMO) score (0–14 points) was constructed with eight pre-ECMO parameters, i.e. age, body mass index, immunocompromised status, prone positioning, days of mechanical ventilation, sepsis-related organ failure assessment, plateau pressure andpositive end-expiratory pressure. Six-month post-ECMO initiation cumulative probabilities of survival were 97, 79, 54 and 16 % for PRESERVE classes 0–2, 3–4, 5–6 and ≥7 (p < 0.001), respectively. HRQL evaluation in 80 % of the 6-month survivors revealed satisfactory mental health but persistent physical and emotional-related difficulties, with anxiety, depression or PTSD symptoms reported, by 34, 25 or 16 %, respectively.

Conclusions

The PRESERVE score might help ICU physicians select appropriate candidates for ECMO among severe ARDS patients. Future studies should also focus on physical and psychosocial rehabilitation that could lead to improved HRQL in this population.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-013-3037-2) contains supplementary material, which is available to authorized users.

Recombinant factor VIIa for uncontrollable bleeding in patients with extracorporeal membrane oxygenation: report on 15 cases and literature review

Introduction

Bleeding is the most frequent complication in patients receiving venoarterial or venovenous extracorporeal membrane oxygenation (ECMO). Recombinant activated factor VII (rFVIIa) has been used in these patients with conflicting results. We describe our experience with rFVIIa for refractory bleeding in this setting and review the cases reported in the literature.

Methods

Clinical characteristics, demographics, bleeding, thrombotic complications, mortality, and rFVIIa administration were retrospectively collected for analysis from the electronic charts of the 15 patients in our intensive care unit who received rFVIIa while being given ECMO from January 2006 to March 2011.

Results

Fifteen patients received rFVIIa for persistent bleeding under venoarterial (n = 11) or venovenous (n = 4) ECMO. Bleeding dramatically decreased in 14 patients, without a major thrombotic event, except in one patient in whom a major stroke could not be ruled out. Two circuits were changed within the 48 hours after rFVIIa administration for clots in the membrane and decreased oxygenation but without massive clotting. The mortality rate was 60%.

Conclusions

rFVIIa use for intractable hemorrhaging in patients receiving ECMO controlled bleeding, without major thrombotic events, and with 60% dying. Hence, its use warrants discussion, and clinicians should be aware of the possibility of potentially life-threatening systemic thrombosis, emboli, or circuit clotting. Whether rFVIIa can save the lives of such patients remains to be determined.

Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation

BACKGROUND

Incidence and impact on adult patients' outcomes of nosocomial infections (NIs) occurring during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock have rarely been described.

METHODS

We retrospectively reviewed the charts of a large series of patients who received VA-ECMO in our intensive care unit (ICU) from January 2003 through December 2009. Incidence, types, risk factors, and impact on outcomes of NIs occurring during ECMO support were analyzed.

RESULTS

Among 220 patients (49 ± 16 years old, simplified acute physiology score (SAPS) II 61 ± 20) who underwent ECMO support for >48 hours for a total of 2942 ECMO days, 142 (64%) developed NIs. Ventilator-associated pneumonia (VAP), bloodstream infections, cannula infections, and mediastinitis infections occurred in 55%, 18%, 10% and 11% of the patients, respectively. More critical condition at ICU admission, but not antibiotics at the time of ECMO cannulation, was associated with subsequently developing NIs (hazard ratio, 0.73; 95% confidence interval [CI], .50-1.05; P = .09). Infected patients had longer durations of mechanical ventilation, ECMO support, and hospital stays. Independent predictors of death were infection with severe sepsis or septic shock (odds ratio, 1.93; 95% CI, 1.26-2.94; P = .002) and SAPS II, whereas immunosuppression and myocarditis as the reason for ECMO support were associated with better outcomes.

CONCLUSIONS

Cardiogenic shock patients who received the latest generation VA-ECMO still had a high risk of developing NIs, particularly VAP. Strategies aimed at preventing these infections may improve the outcomes of these critically ill patients.

Ventilator-associated pneumonia: a comprehensive review

Ventilator-associated pneumonia (VAP) is the most frequent and severe infection acquired in the intensive care unit, leading to prolonged mechanical ventilation and excess mortality. This article reviews the different aspects of VAP, such as risk factors, causative agents, and approaches to diagnosis, treatment, and prevention. Several aspects of VAP are still considered controversial.

Virus-induced acute respiratory distress syndrome: epidemiology, management and outcome

The acute respiratory distress syndrome (ARDS) can be induced by viral diseases, with two virus types being responsible: respiratory viruses that cause community-acquired viral pneumonia and Herpesviridae that cause nosocomial viral pneumonia. Among the respiratory viruses that can affect the lung and cause ARDS, pandemic viruses head the list, with influenza viruses H5N1 and H1N1 2009 being the most recently identified. However, other viruses can cause severe ARDS. Notably, a novel coronavirus was responsible for the severe acute respiratory syndrome outbreak in 2003. Apart from these pandemic viruses, respiratory viruses are rarely responsible for viral pneumonia and ARDS. Other than antiviral drug (mainly oseltamivir) administration and avoidance of corticosteroids, management of ARDS due to these viruses does not differ from that for ARDS caused by other diseases. Among Herpesviridae, herpes simplex virus (HSV) and cytomegalovirus (CMV) are the two viruses causing nosocomial viral pneumonia that can evolve into ARDS. HSV is frequently recovered in the respiratory tract of mechanically ventilated patients and can sometimes be responsible for HSV bronchopneumonitis. Although not evaluated for this indication, acyclovir can be a therapeutic option for patients with HSV bronchopneumonitis and ARDS. CMV pneumonia can also occur in mechanically ventilated patients, but is difficult to diagnose because virus recovery does not necessarily mean viral disease. Ganciclovir can be considered for patients with ARDS and histology- or cytology-proven CMV pneumonia.

Value of the serum procalcitonin level to guide antimicrobial therapy for patients with ventilator-associated pneumonia

Procalcitonin's contribution to the diagnosis of nosocomial infection, particularly ventilator-associated pneumonia (VAP), is poor: its levels in patients with microbiologically documented VAP the day infection is diagnosed range from normal to extremely high. Moreover, the results of four studies showed that, despite relatively good specificity, this marker had low sensitivity for the diagnosis of VAP. However, because procalcitonin is well associated with outcome, its kinetics during antimicrobial therapy can be used to customize that treatment duration. Two recent studies showed that a procalcitonin-based strategy (recommending that treating physicians stop antibiotics when the procalcitonin concentration was <0.5 ng/mL, or had decreased by ≥80%) led to less antibiotic consumption by VAP patients, compared with a conventional strategy, with no adverse outcome. Accordingly, for VAP patients, procalcitonin may be used to stop antibiotics as early as day 3 after their initiation, if its concentration is <0.5 ng/mL or has decreased by ≥80%, compared with the first peak concentration.

Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial

BACKGROUND

Whether early percutaneous tracheotomy in patients who require prolonged mechanical ventilation can shorten mechanical ventilation duration and lower mortality remains controversial.

OBJECTIVE

To compare the outcomes of severely ill patients who require prolonged mechanical ventilation randomly assigned to early percutaneous tracheotomy or prolonged intubation.

DESIGN

Prospective, randomized, controlled, single-center trial (ClinicalTrials.gov registration number: NCT00347321).

SETTING

Academic center.

PATIENTS

216 adults requiring mechanical ventilation 4 or more days after cardiac surgery.

INTERVENTION

Immediate early percutaneous tracheotomy or prolonged intubation with tracheotomy 15 days after randomization.

MEASUREMENTS

The primary end point was the number of ventilator-free days during the first 60 days after randomization. Secondary outcomes included 28-, 60-, or 90-day mortality rates; durations of mechanical ventilation, intensive care unit stay, and hospitalization; sedative, analgesic, and neuroleptic use; ventilator-associated pneumonia rate; unscheduled extubations; comfort and ease of care; and long-term health-related quality of life (HRQoL) and psychosocial evaluations.

RESULTS

There was no difference in ventilator-free days during the first 60 days after randomization between early percutaneous tracheotomy and prolonged intubation groups (mean, 30.4 days [SD, 22.4] vs. 28.3 days [SD, 23.7], respectively; absolute difference, 2.1 days [95% CI, -4.1 to 8.3 days]) nor in 28-, 60-, or 90-day mortality rates (16% vs. 21%, 26% vs. 28%, and 30% vs. 30%, respectively). The durations of mechanical ventilation and hospitalization, as well as frequencies of ventilator-associated pneumonia and other severe infections, were also similar. However, early percutaneous tracheotomy was associated with less intravenous sedation; less time of heavy sedation; less haloperidol use for agitation, delirium, or both; fewer unscheduled extubations; better comfort and ease of care; and earlier resumption of oral nutrition. After a median follow-up of 873 days, between-group survival, psychosocial evaluations, and HRQoL were similar.

LIMITATION

The prolonged intubation group had more ventilator-free days during days 1 to 60 than what was hypothesized (mean, 23.0 days [SD, 17.0]).

CONCLUSION

Early tracheotomy provided no benefit in terms of mechanical ventilation and length of hospital stay, rates of mortality or infectious complications, and long-term HRQoL for patients who require prolonged mechanical ventilation after cardiac surgery. However, the well-tolerated procedure was associated with less sedation, better comfort, and earlier resumption of autonomy.

PRIMARY FUNDING SOURCE

French Ministry of Health.

Diagnostic techniques and procedures for establishing the microbial etiology of ventilator-associated pneumonia for clinical trials: the pros for quantitative cultures

Use of only clinical criteria for enrolling patients in clinical trials leads to inclusion of many patients who have no pulmonary infection, which can make the evaluation of new treatment modalities difficult. Quantitative cultures of specimens obtained using bronchoscopic or nonbronchoscopic techniques, such as bronchoalveolar lavage and/or protected specimen brush, are much more specific and could improve identification of patients with ventilator-associated pneumonia. Microscopic examination of distal respiratory secretions with use of Gram staining permits randomizing only patients with a high probability of ventilator-associated pneumonia and, thus, avoids the potential bias that can result from secondary exclusions. Invasive techniques also offer a sensitive and specific approach for identifying the responsible microorganisms, which is particularly important when evaluating antimicrobial agents for which bactericidal activity can be highly variable from one pathogen to another. Follow-up evaluation of the infected site with use of the same techniques permits determination of the pharmacokinetic and/or pharmacodynamic parameters of the new agents and their microbiological efficacy, compared with current antibiotics.

Severe imported falciparum malaria: a cohort study in 400 critically ill adults

Background

Large studies on severe imported malaria in non-endemic industrialized countries are lacking. We sought to describe the clinical spectrum of severe imported malaria in French adults and to identify risk factors for mortality at admission to the intensive care unit.

Methodology and Principal Findings

Retrospective review of severe Plasmodium falciparum malaria episodes according to the 2000 World Health Organization definition and requiring admission to the intensive care unit. Data were collected from medical charts using standardised case-report forms, in 45 French intensive care units in 2000–2006. Risk factors for in-hospital mortality were identified by univariate and multivariate analyses.

Data from 400 adults admitted to the intensive care unit were analysed, representing the largest series of severe imported malaria to date. Median age was 45 years; 60% of patients were white, 96% acquired the disease in sub-Saharan Africa, and 65% had not taken antimalarial chemoprophylaxis. Curative quinine treatment was used in 97% of patients. Intensive care unit mortality was 10.5% (42 deaths). By multivariate analysis, three variables at intensive care unit admission were independently associated with hospital death: older age (per 10-year increment, odds ratio [OR], 1.72; 95% confidence interval [95%CI], 1.28–2.32; P = 0.0004), Glasgow Coma Scale score (per 1-point decrease, OR, 1.32; 95%CI, 1.20–1.45; P<0.0001), and higher parasitemia (per 5% increment, OR, 1.41; 95%CI, 1.22–1.62; P<0.0001).

Conclusions and Significance

In a large population of adults treated in a non-endemic industrialized country, severe malaria still carried a high mortality rate. Our data, including predictors of death, can probably be generalized to other non-endemic countries where high-quality healthcare is available.

Controversies in ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection among patients receiving mechanical ventilation. Consensus, however, on the most appropriate diagnostic strategy for patients clinically suspected of having developed VAP has yet to be reached. Concern about the inaccuracy of clinical approaches to VAP recognition and potential for excessive use of antibiotics in the ICU had led numerous investigators to postulate that quantitative cultures of specimens obtained with bronchoscopic or nonbronchoscopic techniques, such as bronchoalveolar lavage (BAL) and/or protected specimen brush (PSB), could improve identification of patients with true VAP and facilitate decisions whether to treat. Other than decision-analysis studies and one retrospective study, only five trials assessed the impact of such a quantitative bacteriological strategy on antibiotic use and outcome of patients suspected of VAP using a randomized scheme. In one study, the invasive management strategy was significantly associated with earlier attenuation of organ dysfunction and less antibiotic exposure, but the four other trials could not replicate these positive findings, including a large Canadian study that enrolled 740 patients. Because antibiotics were continued in most patients with negative BAL cultures in contradiction with the bacteriological algorithm, additional studies will be needed before concluding that a strategy based on the systematic collection of distal pulmonary secretions before introduction of new antibiotics and quantitative culture techniques is useless and cannot prevent the overuse of antimicrobial agents in the ICU.

Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients

OBJECTIVE

Although several advantages are attributed to tracheotomy in ICU patients requiring mechanical ventilation (MV), true benefits and the optimal timing of tracheotomy remain controversial. In this study, we compared early tracheotomy (ET) with prolonged intubation (PI) in severely ill patients requiring prolonged MV.

DESIGN

Prospective, randomized study.

SETTING

Twenty-five medical and surgical ICUs in France.

PATIENTS

Patients expected to require MV > 7 days.

MEASUREMENTS AND RESULTS

Patients were randomised to either (open or percutaneous) ET within 4 days or PI. The primary end-point was 28-day mortality. Secondary end-points were: the incidence of ICU-acquired pneumonia, number of d1-d28 ventilator-free days, time spent in the ICU, 60-day mortality, number of septic episodes, amount of sedation, comfort and laryngeal and tracheal complications. A sample size of 470 patients was considered necessary to obtain a reduction from 45 to 32% in 28-day mortality. After 30 months, 123 patients had been included (ET = 61, PI = 62) in 25 centres and the study was prematurely closed. All group characteristics were similar upon admission to ICU. No difference was found between the two groups for any of the primary or secondary end-points. Greater comfort was the sole benefit afforded by tracheotomy after subjective self-assessment by patients.

CONCLUSIONS

The trial did not demonstrate any major benefit of tracheotomy in a general population of ICU patients, as suggested in a previous meta-analysis, but was underpowered to draw any firm conclusions. The potential advantage of ET may be restricted to selected groups of patients.

Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?

OBJECTIVE

To evaluate the effect of tracheostomy on intensive care unit (ICU) and in-hospital mortality for patients requiring prolonged (> 3 days) mechanical ventilation (MV).

DESIGN, SETTING, AND PATIENTS

We retrospectively reviewed the charts of all consecutive patients admitted to our 18-bed tertiary care ICU over 3 yrs (2002-2004) and who received prolonged MV. Outcomes of tracheostomized and nontracheostomized patients were evaluated using univariable and multivariable logistic-regression analyses and by constructing a case-control cohort using a propensity score for performing tracheostomy. MV duration for controls was at least equal to the time from MV onset to tracheostomy for the matched case.

MEASUREMENTS AND MAIN RESULTS

Of the 506 patients requiring prolonged MV, 166 were tracheostomized after a median of 12 days of MV. Nontracheostomized patients had higher ICU (42% vs. 33%, p = .06) and in-hospital (48% vs. 37%, p = .03) mortality rates and shorter MV durations and ICU lengths of stay. Performing a tracheostomy (odds ratio, 0.58; 95% CI, 0.37-0.90) was independently associated with a lower probability of ICU death, even after adjusting for other important prognostic factors. No significant differences were detected between the 120 cases and their matched controls regarding ICU admission and day-3 clinical characteristics. After conditional logistic-regression analysis, tracheostomy was associated with lower risk of ICU (odds ratio, 0.47; 95% CI, 0.24-0.89) and in-hospital (odds ratio, 0.48; 95% CI, 0.25-0.90) death.

CONCLUSIONS

Tracheostomy performed in our ICU for long-term MV patients was associated with lower ICU and in-hospital mortality rates, even after carefully controlling for ICU admission and day-3 clinical and physiologic differences between groups. Whether these results reflect that physicians were able to adequately select for tracheostomy patients who, despite having similar physiologic and demographic variables, had the highest probabilities of survival or that the procedure itself really affected the outcomes of these patients will remain speculative.

Does invasive diagnosis of nosocomial pneumonia during off-hours delay treatment?

OBJECTIVE

We examined whether invasive lung-specimen collection-to-treatment times for intensive care unit patients with suspected ventilator-associated pneumonia (VAP) differ with to the work shift during which specimens were collected. We compared weekday day shifts and off-hours (from 6:30 p.m. to 8:29 a.m. the next day for night shifts, from Saturday 1:00 p.m. to Monday 8:29 a.m. for weekends, and from 8:30 a.m. to 8:29 a.m. the following morning for public holidays).

DESIGN AND SETTING

Single-center, observational study in the intensive care unit in an academic teaching hospital.

PATIENTS AND PARTICIPANTS

101 patients who developed 152 episodes of bacteriologically confirmed VAP.

MEASUREMENTS AND RESULTS

Of the 152 VAP episodes 66 were diagnosed during off-hours. Neither more bronchoscopy complications nor more inappropriate initial antimicrobial treatments for patients were observed between day and off-hour shifts. Indeed, the overall time from brochoalveolar lavage to antibiotic administration was shorter for off-hours than day-shifts due to shorter specimen collection-to-antibiotic prescription times, but antibiotic prescription-to-administration times were the same.

CONCLUSIONS

An invasive strategy based on bronchoscopy to diagnose VAP was not associated with a longer time to first appropriate antibiotic administration when clinical suspicion of VAP occurs during off-hours.

Early predictors for infection recurrence and death in patients with ventilator-associated pneumonia

OBJECTIVE

Early recognition of predictors of unfavorable evolution of ventilator-associated pneumonia (VAP) might prompt therapeutic measures that might improve outcome. The objective of this study was to describe resolution of VAP variables and to determine early predictors of VAP recurrence and death.

DESIGN AND SETTING

Description of the natural course of VAP resolution and multivariable analyses of predictors of VAP recurrence and death by day 28 after VAP onset based on the 401 patients included in the PNEUMA trial, a multiple-center, randomized study comparing 8 vs. 15 days of antibiotics for microbiologically proven VAP. Every patient included in that trial had received appropriate empirical antibiotics.

MEASUREMENTS AND MAIN RESULTS

By day 28 after VAP onset, 27% of patients had VAP recurrence and 18% had died. On day 8 after VAP onset, predictors of VAP recurrence included intensive care unit admission Simplified Acute Physiology Score II (odds ratio [OR], 1.02), radiologic score (OR, 1.17), temperature (OR, 1.34), nonfermenting Gram-negative bacilli (OR, 2.00) or methicillin-resistant Staphylococcus aureus (OR, 2.50) as pathogens responsible for VAP, and mechanical ventilation dependency (OR, 2.08). Day 8 predictors of 28-day death were age (OR, 1.06), female sex (OR, 2.30), Sepsis-Related Organ Failure Assessment score (OR, 1.26), and nonfermenting Gram-negative bacilli (OR, 2.83) as pathogens responsible for VAP. However, the duration of antimicrobial therapy (8 vs. 15 days) was not associated with any of the studied adverse outcomes.

CONCLUSIONS

For patients benefiting from appropriate empirical antibiotics for VAP, early predictors of infection recurrence or death included demographic characteristics, such as age or female sex, disease severity at VAP onset, nonfermenting Gram-negative bacilli or methicillin-resistant S. aureus as VAP-causative pathogens, prolonged mechanical ventilation dependency, persistent fever, and severity of lung injury. Future studies should attempt to determine whether specific diagnostic or therapeutic strategies could markedly improve VAP outcomes when early criteria for treatment failure are present.

Herpes simplex virus lung infection in patients undergoing prolonged mechanical ventilation

RATIONALE

It is not known whether the isolation of herpes simplex virus (HSV) from lower respiratory tract samples of nonimmunocompromised ventilated patients corresponds to bronchial contamination from the mouth and/or throat, local tracheobronchial excretion of HSV, or true HSV lung involvement (bronchopneumonitis) with its own morbidity/mortality.

OBJECTIVES

This prospective, single-center, observational study was conducted to define the frequency, risk factors, and relevance of HSV bronchopneumonitis.

METHODS

All consecutive nonimmunocompromised patients receiving mechanical ventilation for 5 days or more were evaluated. Bronchoalveolar lavage, oropharyngeal swabs, and bronchial biopsies (presence of macroscopic bronchial lesions) were obtained for all who deteriorated clinically with suspected lung infection. HSV bronchopneumonitis was defined as this deterioration, associated with HSV in bronchoalveolar lavage and HSV-specific nuclear inclusions in cells recovered during lavage or bronchial biopsies.

MEASUREMENTS AND MAIN RESULTS

HSV bronchopneumonitis was diagnosed in 42 (21%) of the 201 patients who deteriorated clinically, with a mean mechanical ventilation duration before diagnosis of 14 +/- 6 days. Risk factors associated with HSV bronchopneumonitis were oral-labial lesions, HSV in the throat, and macroscopic bronchial lesions seen during bronchoscopy. Patients with HSV bronchopneumonitis were comparable to those without at admission, but their courses were more complicated, with longer duration of mechanical ventilation and intensive care unit stays.

CONCLUSIONS

HSV bronchopneumonitis is common in nonimmunocompromised patients with prolonged mechanical ventilation, is associated with HSV reactivation or infection of the mouth and/or throat, and seems to be associated with poorer outcome.

Mortality among patients admitted to intensive care units during weekday day shifts compared with "off" hours

OBJECTIVE

To determine whether mortality rates among intensive care unit (ICU) patients differ according to the time of ICU admission, we compared the death rates for patients admitted during weekday day shifts and off hours (from 6:30 pm to 8:29 am the next day for night shifts, from Saturday 1:00 pm to Monday 8:29 am for weekends, and from 8:30 am to 8:29 am the following morning for public holidays).

METHODS

Retrospective cohort study of data collected prospectively from 23 ICUs located in the Paris metropolitan region, France. Between January 2000 and December 2003, 51,643 patients were admitted to these ICUs. Patients were grouped according to their day and time of admission and compared using univariable and multivariable analyses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 51,643 patients admitted to ICUs, 33,857 (65.6%) were admitted during off hours. These latter patients were less critically ill than those admitted during day shifts, had fewer failed organs, required fewer support procedures, and their crude in-hospital mortality was lower (20.7 vs. 24.5%, p < .0001). After adjustment for initial disease severity, in-hospital mortality was not higher for off-hours admissions than weekday day admissions and even remained slightly lower (adjusted odds ratio, 0.93; 95% confidence interval, 0.87-0.98).

CONCLUSIONS

Admission during off hours is common. In our ICUs, off-hours admissions were not associated with higher mortality and might even be associated with a lower death rate.

Native-valve infective endocarditis caused by Enterobacteriaceae: report on 9 cases and literature review

Although the demographic characteristics of patients who develop infective endocarditis (IE) have changed over the last few decades, Enterobacteriaceae remain rarely responsible. We report the clinical and epidemiological characteristics of 9 patients with native-valve Enterobacteriaceae IE from 6 French medical intensive care units over a 10-y period and have identified 29 additional cases in the literature. Nearly a third of the 38 patients were immunocompromised and/or had previously known valvular heart disease. Salmonella spp. and Yersinia spp. were the most frequently isolated microorganisms reported in the literature. The overall mortality rate was 24% (9/38) and was lower for operated patients (10% (1/10)) compared to those who did not undergo valve surgery (31% (8/26)). Our results confirmed the rarity of native-valve endocarditis caused by Enterobacteriaceae, pathogens frequently responsible for nosocomial and community-acquired bacteraemias. This paradox may be explained by susceptibility to the bactericidal action of serum and the inability of these bacteria to colonize the endocardium.

New diagnostic and prognostic markers of ventilator-associated pneumonia

PURPOSE OF REVIEW

The purpose of this review is to analyze the potential advantages and drawbacks of using biomarkers of bacterial infection for the diagnosis and prognosis of ventilator-associated pneumonia.

RECENT FINDINGS

Whereas procalcitonin and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) have both greater diagnostic accuracies than most commonly used clinical parameters and other biomarkers of infection, such as C-reactive protein, they can be increased in noninfectious conditions or remain low in patients with true infection. Furthermore, these assays cannot determine the causative organisms and associated patterns of antibiotic susceptibility.

SUMMARY

Procalcitonin and sTREM-1 should be used only as a complementary tool, to reinforce the usual diagnostic work-up. However, serial serum procalcitonin and sTREM-1 measurements may provide an opportunity to change the treatment early in the course of patients with ventilator-associated pneumonia, either to intensify treatment when their levels stay high, or to avoid unnecessary prolonged courses of antibiotics when their levels rapidly decrease. Whether procalcitonin and/or sTREM-1 guidance can reduce antibiotic use in such a setting will require additional studies, but such a strategy appears promising.

Impact of piperacillin resistance on the outcome of Pseudomonas ventilator-associated pneumonia

BACKGROUND

The impact of antibiotic resistance on the outcome of infections due to Gram-negative bacilli, especially Pseudomonas, remains highly controversial. STUDY OBJECTIVE, DESIGN, AND PATIENTS: We evaluated the impact of piperacillin resistance on the outcomes of Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) for patients who had received appropriate empiric antibiotics before enrollment in the PNEUMA trial, a multicenter randomized study comparing 8 vs 15 days of antibiotics.

RESULTS

Despite similar characteristics at intensive care unit (ICU) admission, patients infected with piperacillin-resistant Pseudomonas strains were more acutely ill at VAP onset and had a higher 28-day mortality rate (37 vs 19%; P = 0.04) than those with piperacillin-susceptible Pseudomonas VAP. Factors associated with 28-day mortality retained by multivariable analysis were: age (OR: 1.07; 95% CI: 1.03-1.12); female gender (OR: 4.00; 95% CI: 1.41-11.11); severe underlying comorbidities (OR: 2.73; 95% CI: 1.02-7.33); and SOFA score (OR: 1.17; 95% CI: 1.03-1.32), but piperacillin resistance did not reach statistical significance (OR: 2.00; 95% CI: 0.72-5.61). The VAP recurrence rates, either superinfection or relapse, and durations of mechanical ventilation and ICU stay did not differ as a function of Pseudomonas-resistance status.

CONCLUSIONS

For patients with Pseudomonas VAP benefiting from appropriate empiric antibiotics, piperacillin resistance was associated with increased disease severity at VAP onset and higher 28-day crude mortality; however, after controlling for confounders, piperacillin-resistance was no longer significantly associated with 28-day mortality. The VAP recurrence rates and durations of ICU stay and mechanical ventilation did not differ for susceptible and resistant strains.

Use of quantitative cultures and reduced duration of antibiotic regimens for patients with ventilator-associated pneumonia to decrease resistance in the intensive care unit

Ventilator-associated pneumonia is responsible for approximately half of the infections acquired in the intensive care unit and represents one of the principal reasons for the prescription of antibiotics in this setting. Invasive diagnostic methods, including bronchoalveolar lavage and/or protected specimen bronchial brushing, could improve the identification of patients with true bacterial pneumonia and facilitate decisions of whether to treat. These techniques also permit rapid optimization of the choice of antibiotics in patients with proven bacterial infection, once the results of respiratory tract cultures become available, based on the identity of the specific pathogens and their susceptibility to specific antibiotics, to avoid prolonged use of a broader spectrum of antibiotic therapy than is justified by the available information. Because unnecessary prolongation of antibiotic therapy for patients with true bacterial infection may lead to the selection of multidrug-resistant microorganisms without improving clinical outcome, efforts to reduce the duration of therapy for nosocomial infections are also warranted. An 8-day regimen can probably be standard for patients with ventilator-associated pneumonia. Possible exceptions to this recommendation include immunosuppressed patients, patients who are bacteremic or whose initial antibiotic therapy was not appropriate for the causative microorganism(s), and patients whose infection is with very difficult-to-treat microorganisms and show no improvement in clinical signs of infection.

Impact of Antibiotic-Resistant Bacteria on the Outcome of Ventilator-Associated Pneumonia

Since antibiotic resistance has become a worldwide concern, there has been an ongoing debate as to whether infections caused by resistant bacteria are associated with higher mortality. Because resistant strains do not appear to be more virulent, differences in outcome may principally relate to patients' characteristics before or at the time of infection onset, and to high rates of inappropriate empirical antimicrobial treatment prescribed for antibiotic-resistant infections. In two large series of severe Staphylococcus aureus and Pseudomonas aeruginosa ventilator-associated pneumonia, we recently demonstrated that antibiotic resistance does not significantly affect intensive care unit mortality of patients receiving appropriate initial antibiotics. However, antibiotic resistance was consistently found to increase hospital length of stay. Early identification of patients with risk factors favoring antibiotic-resistant infections should prompt the initiation of an empirical antibiotic regimen covering these highly resistant bacteria, which can usually be deescalated 48 to 72 hours later when the results of microbiological samples culture become available.

Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients*

OBJECTIVE

To assess the impact of tracheotomy on sedative administration, sedation level, and autonomy of mechanically-ventilated intensive care unit (ICU) patients.

DESIGN, SETTING, AND PATIENTS

In this observational study, the charts of all consecutive patients undergoing mechanical ventilation requiring tracheotomy over a 14-month period in our 18-bed tertiary care ICU were reviewed retrospectively. Patients' sedation levels (according to the Riker's 7-level sedation-agitation score) and intravenous (fentanyl and midazolam) and oral (clorazepate and haloperidol) sedative administration were measured daily during the 7 days before and after tracheotomy. We also recorded patients for whom chair positioning and oral alimentation became possible in the days following tracheotomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Tracheotomy was performed on 72 (23.1%) of the 312 patients undergoing mechanical ventilation for > or = 48 hrs. After tracheotomy, median (25th, 75th percentiles) fentanyl and midazolam administration decreased from 866 (191, 1672) to 71 (3, 426) microg/(patient.day) and from 44 (16, 128) to 7 (1, 42) mg/(patient.day) (p < .001), respectively. Concomitant median time spent heavily sedated decreased from 7 (3, 17) to 1 (0, 6) hrs/day (p < .001), with no increase in agitation time. During the 7 days following tracheotomy, partial oral alimentation became possible for 35 patients (48.6%) and out-of-bed positioning became possible for 16 patients (22.2%).

CONCLUSION

On the basis of these observations, we conclude that tracheotomized mechanically ventilated ICU patients required less intravenous sedative administration, spent less time heavily sedated, and achieved more autonomy earlier.

Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units

OBJECTIVE

To evaluate the effectiveness of screening strategy and contact precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA).

DESIGN AND SETTING

Prospective observational cohort from 1 February 1995 to 31 December 2001 in three intensive care units (45 beds) in a French teaching hospital.

PATIENTS

8,548 patients admitted to the three ICUs had nasal screening on ICU admission and weekly thereafter. Contact precautions were used in MRSA-positive patients. The following variables were collected: age, gender, severity score, length of stay, workload, and colonization pressure (percentage of patient-days with an MRSA to the number of patient-days in the unit). Alcohol-based handrub solution was introduced in July 2000. We compared the period before this (P1) with that thereafter (P2).

RESULTS

Of the 8,548 admitted patients 554 (6.5%) had MRSA at ICU admission, and 456 of the 7,515 (6.1%) exposed patients acquired MRSA. Acquisition incidence decreased from 7.0% in P1 to 2.8% in P2. Independent variables associated with MRSA acquisition were: age (adjusted odds ratio 1.013), severity score (1.047), length of ICU stay (1.015), colonization pressure (1.019), medical ICU (1.58), and P2 (0.49).

CONCLUSIONS

MRSA control in these ICUs characterized by a high prevalence of MRSA at admission was achieved via multiple factors, including screening, contact precautions, and use of alcoholic handrub solution. Our results after adjustment of risk factors for MRSA acquisition and the steady improvement in MRSA over several years strengthen these findings. MRSA spreading can be successfully controlled in ICUs with high colonization pressure.

Adverse effect on a referral intensive care unitʼs performance of accepting patients transferred from another intensive care unit*

OBJECTIVE

To determine whether observed and predicted mortality for intensive care unit (ICU) transfer admissions is different from non-ICU transfer admissions and how that might affect ICU performance evaluation.

DESIGN, SETTING, AND PATIENTS

We retrospectively analyzed the charts of 3,416 patients admitted to our tertiary referral ICU from January 1995 to December 2001 and evaluated the effect on our performance (based on the Simplified Acute Physiology Score II risk model) of accepting patients transferred from another hospital's ICU.

MAIN RESULTS

During the study period, 597 patients (17%) had been transferred from a non-ICU setting in another hospital (hospital transfer) and 408 (12%) from another hospital's ICU (ICU transfer). ICU mortality and standardized mortality ratios were significantly higher for ICU-transfer patients than for hospital-transfer or directly admitted patients: 34% vs. 23% vs. 17% (p < .0001) and 0.95 (95% confidence interval, 0.83-1.08), 0.82 (95% confidence interval, 0.71-0.95), and 0.62 (95% confidence interval, 0.55-0.68), respectively. ICU-transfer patients had 3.6-fold longer mean ICU stays and 1.9-fold longer durations of mechanical ventilation than directly admitted patients. Hospital-transfer (odds ratio = 1.89) and ICU-transfer patients (odds ratio = 2.41) had significantly higher mortality rates, even after adjustment for case mix and disease severity. Consequently, a benchmarking program adjusting only for these latter variables, but not admission source, would penalize our ICU by 39 excess deaths per 1,000 admissions as compared with another ICU admitting no transfer patients. Finally, patients transferred from the ward of another hospital had significantly higher mortality rates (odds ratio = 1.56) as compared with patients directly admitted from the ward of our hospital, confirming the "transfer effect" for this homogeneous patients' subgroup.

CONCLUSIONS

Admission source remains a strong and independent predictor of ICU death, despite adjustment for case mix and disease severity at ICU admission. Specifically, accepting numerous ICU-transfer patients, for whom the probability of ICU death is the most underestimated by a system adjusting only for case mix and disease severity, can adversely affect the evaluation of referral centers' performance. Future benchmarking and profiling systems should evaluate and adequately account for the ICU-transfer factor to provide healthcare payers and consumers with more accurate and valid information on the true performance of referral centers.

Acute poststernotomy mediastinitis managed with debridement and closed-drainage aspiration: Factors associated with death in the intensive care unit

OBJECTIVE

The purpose of the study is to describe an intensive care unit's experience in the treatment of poststernotomy mediastinitis and to identify factors associated with intensive care unit death.

METHODS

Over a 10-year period, 316 consecutive patients with mediastinitis occurring less than 30 days after sternotomy were treated in a single unit. First-line therapy was closed-drainage aspiration with Redon catheters. Variables recorded, including patient demographics, underlying disease classification, clinical and biologic data available at intensive care unit admission and day 3, and their association with intensive care unit mortality, were subjected to multivariate analyses.

RESULTS

Intensive care unit mortality (20.3%) was significantly associated with 5 variables available at admission: age greater than 70 years (odds ratio, 2.70), operation other than coronary artery bypass grafting alone (odds ratio, 2.59), McCabe class 2/3 (odds ratio, 2.47), APACHE II score (odds ratio, 1.12 per point), and organ failure (odds ratio, 2.07). After introducing day 3 variables into the logistic regression model, independent risk factors for intensive care unit death were as follows: age greater than 70 years, operations other than coronary artery bypass grafting alone, McCabe class 2/3, APACHE II score, mechanical ventilation still required on day 3, and persistently positive bacteremia. For patients receiving mechanical ventilation for less than 3 days, mortality was very low (2.4%). In contrast, for patients receiving mechanical ventilation for 3 days or longer, mortality reached 52.8% and was associated with non-coronary artery bypass grafting cardiac surgery, persistently positive bacteremia, and underlying disease.

CONCLUSIONS

In patients requiring intensive care for acute poststernotomy mediastinitis, age, type of cardiac surgery, underlying disease, and severity of illness at the time of intensive care unit admission were associated with intensive care unit death. Two additional factors (mechanical ventilation dependence and persistently positive bacteremia) were identified when the analyses were repeated with inclusion of day 3 patient characteristics.

Impact of Methicillin Resistance on Outcome ofStaphylococcus aureusVentilator-associated Pneumonia

The impact of methicillin resistance on morbidity and mortality of patients suffering from severe Staphylococcus aureus infections remains highly controversial. We analyzed a retrospective cohort of 97 patients with methicillin-susceptible and 74 patients with methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia (VAP). Initial empiric antibiotic therapy was appropriate for every patient. Patients with methicillin-resistant Staphylococcus aureus VAP were older, had higher disease-severity scores, and had been on mechanical ventilation longer at onset of VAP. Factors associated with 28-day mortality retained by multivariate logistic regression analysis were: age (odds ratio [OR] = 1.05, 95% confidence interval [CI], 1.02-1.08, p = 0.001) and Day 1 organ dysfunctions or infection (ODIN) score (OR = 1.90, 95% CI, 1.31-2.78, p = 0.001), but not methicillin resistance (OR = 1.72, 95% CI, 0.73-4.05, p = 0.22). The percentages of infection relapse or superinfection did not differ significantly between the two patient groups. In conclusion, after controlling for clinical and physiologic heterogeneity between groups, methicillin resistance did not significantly affect 28-day mortality of patients with Staphylococcus aureus VAP receiving appropriate antibiotics.

Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia

We investigated the value of procalcitonin kinetics as a prognostic marker during ventilator-associated pneumonia (VAP). This prospective, observational study was conducted in a medical intensive care unit in a university hospital. All consecutive patients with microbiologically proven VAP who survived 3 days after its diagnosis were included and grouped according to clinical outcome: favorable or unfavorable, defined as death, VAP recurrence, or extrapulmonary infection requiring antibiotics before Day 28. Serum procalcitonin levels were measured on Days 1, 3, and 7 for all patients. Among the 63 patients included, 38 had unfavorable outcomes. On Day 1, they were more critically ill than patients with a favorable outcome. Serum procalcitonin levels decreased during the clinical course of VAP but were significantly higher from Day 1 to Day 7 in patients with unfavorable outcomes. Multivariate analyses retained serum procalcitonin levels on Days 1, 3, and 7 as strong predictors of unfavorable outcome. Based on these data, procalcitonin could be a prognostic marker of outcome during VAP.

Infective endocarditis in the intensive care unit: clinical spectrum and prognostic factors in 228 consecutive patients

OBJECTIVE

To identify factors associated with in-hospital outcome of adult patients admitted to the ICU with infective endocarditis (IE).

DESIGN AND SETTING

Retrospective study performed in the two medical ICUs of a teaching hospital.

PATIENTS AND PARTICIPANTS

The charts of all 228 consecutive patients aged 18 years or older admitted with infective IE between January 1993 and December 2000 were reviewed. All patients satisfied the modified Duke's criteria for definite IE.

MEASUREMENTS AND RESULTS

There were 146 episodes of native valve endocarditis and 82 of prosthetic valve endocarditis. Staphylococcus aureus was the predominant causative micro-organism. Most complications occurred early during the course of IE. One-half of the patients underwent cardiac surgery during the same hospitalization and had a better outcome than nonoperated patients. The overall in-hospital mortality rate was 45% (102/228). Multivariate analysis revealed the following clinical factors in patients with native valve IE as independently associated with outcome: septic shock (odds ratio 4.81), cerebral emboli (3.00), immunocompromised state (2.88), and cardiac surgery (0.475); in patients with prosthetic valve IE the factors were: septic shock (4.07), neurological complications (3.1), and immunocompromised state (3.46).

CONCLUSIONS

IE still carries high morbidity and mortality rates for the subset of patients requiring ICU admission. Most complications occur early making the decision process for optimal medical and surgical management more difficult. Surgical treatment appears to improve in-hospital outcome.

Estimation of left ventricular systolic function by single transpulmonary thermodilution

OBJECTIVE

The single-indicator transpulmonary thermodilution technique (PiCCO system) provides two derived indices of cardiac systolic function: the cardiac function index and the global ejection fraction. We used transesophageal echocardiography to compare theses indices with left ventricular fractional area of change only for patients with no isolated right ventricular dysfunction. (The global cardiac systolic function may be decreased despite preserved left ventricular function in this situation.)

DESIGN

Prospective, open, clinical study.

SETTING

Intensive care unit (ICU) in a university hospital.

PATIENTS

Thirty-three mechanically ventilated patients.

INTERVENTION

Left ventricular fractional area of change (LVFAC) was measured using transesophageal echocardiography. The cardiac function index (CFI) and the global ejection fraction (GEF) were determined from transpulmonary thermodilution-derived cardiac output and thoracic volumes.

MEASUREMENTS AND MAIN RESULTS

Transesophageal echocardiography identified 3 patients with isolated right ventricular failure (PiCCO underestimated LVFAC in this situation). Significant correlations were established between LVFAC and CFI (r=0.87, n=30, p<0.0001) or GEF (r=0.82, n=30, p<0.0001). The mean differences between measured LVFAC and LVFAC estimated with CFI or GEF were 0.8+/-8.5% (range: -17 to 14%) and 0.8+/-9.0% (range: -21 to 19%), respectively. Area under the receiver operating characteristics curves for the estimation of LVFAC >/=40% using CFI or GEF was 0.92. CFI >4 and GEF >18% estimated LVFAC >/=40% with respective sensitivities of 86 and 88% and specificities of 88 and 79%. Significant correlations were established between changes of LVFAC and CFI/GEF over time.

CONCLUSIONS

In mechanically ventilated ICU patients, PiCCO-derived cardiac function index and global ejection fraction provide reliable estimations of LV systolic function but may underestimate it in the cases of isolated right ventricular failure.

Clinical and autopsy diagnoses in the intensive care unit: a prospective study

BACKGROUND

Autopsy rates have declined worldwide, but recent retrospective intensive care unit (ICU) data indicate major discrepancies between more than 25% of clinical and autopsy diagnoses.

METHODS

We conducted a 3-year prospective study of all consecutive autopsies performed on patients who died in a university hospital medical-surgical ICU to determine how many might have benefited from a different level of care, had the autopsy diagnosis been made before death. All clinical diagnoses were compared with autopsy findings at monthly clinical-pathological meetings. Major and minor diagnostic discrepancies were categorized according to the criteria of Goldman et al.

RESULTS

Of 1492 patients admitted to the ICU, 315 died, of whom 167 (53.0%) were autopsied. The most common reason (79.7%) for not obtaining an autopsy was family refusal. The mean +/- SD clinical characteristics were similar for autopsied vs nonautopsied patients, except for shorter length of ICU stay (13 +/- 17 vs 20 +/- 27 days, P =.006), shorter duration of mechanical ventilation (13 +/- 16 vs 19 +/- 25 days, P =.01), and lower percentage of postcardiac surgery patients (38.9% vs 50.0%, P =.05). Among the intensivists' 694 clinical diagnoses, 33 (4.8%) were refuted and 13 (1.9%) were judged incomplete by autopsy findings. Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others. Major diagnostic errors (class I and class II discrepancies) were made in 53 (31.7%) of 167 patients, with a high percentage of immunocompromised patients also observed among these. Similar percentages of patients with class I and class II errors vs other patients had undergone modern diagnostic techniques during their ICU stay.

CONCLUSION

Even in the era of modern diagnostic technology, regular comparisons of clinical and autopsy diagnoses provide pertinent information that might improve future management of ICU patients.