Risk factors and prognostic significance of infection of totally implantable vascular access port in solid tumor patients: A prospective cohort study

OBJECTIVES

Totally implantable venous access ports (TIVAP) are devices mainly used to deliver antineoplastic chemotherapies, of which the insertion may be complicated by TIVAP-related infection (TIVAP-RI). This study aims to provide data on the risk factors for TIVAP-RI and its influence on patient prognosis.

PATIENTS AND METHODS

Prospective observational study including adult patients with solid tumors, in whom a TIVAP was inserted to deliver antineoplastic chemotherapy between January 2018 and October 2019. Factors associated with TIVAP-RI and one-year mortality were determined using multiple logistic regressions.

RESULTS

More than a thousand (1014) patients were included, among whom 48 (4.7%) presented with TIVAP-RI. Gram-positive cocci and Gram-negative bacilli represented 51% and 41% of the pathogens isolated, respectively. Young age (odds ratio [OR] 0.67; 95% Confidence Interval [0.53-0.83] per 10-year increase), WHO performance status ≥ 1 (OR 3.24 [1.52-7.79]), chemotherapy administration in the month before TIVAP placement (OR 2.26 [1.17-4.26]), and radiation therapy of the homolateral chest wall (OR 3.28 [1.51-6.67]) were independently associated with TIVAP-RI occurrence. During the year following TIVAP insertion, 287 (28%) patients died. TIVAP-RI was not associated with one-year mortality (OR 1.56 [0.75-3.19]).

CONCLUSION

TIVAP insertion in adult patients with solid tumors is associated with a low infection rate, which did not influence one-year mortality. In addition to young age and impaired health status, TIVAP insertion in the month following initiation of the antineoplastic chemotherapy and TIVAP insertion in an irradiated area are two newly reported preventable TIVAP-RI risk factors.

Pain and dyspnea control during awake fiberoptic bronchoscopy in critically ill patients: safety and efficacy of remifentanil target-controlled infusion

Purpose

Flexible fiberoptic bronchoscopy is frequently used in intensive care unit, but is a source of discomfort, dyspnea and anxiety for patients. Our objective was to assess the feasibility and tolerance of a sedation using remifentanil target-controlled infusion, to perform fiberoptic bronchoscopy in awake ICU patients.

Materials, patients and methods

This monocentric, prospective observational study was conducted in awake patients requiring fiberoptic bronchoscopy. In accordance with usual practices in our center, remifentanil target-controlled infusion was used under close monitoring and adapted to the patient’s reactions. The primary objective was the rate of successful procedures without additional analgesia or anesthesia. The secondary objectives were clinical tolerance and the comfort of patients (graded from “very uncomfortable” to “very comfortable”) and operators (numeric scale from 0 to 10) during the procedure.

Results

From May 2014 to December 2015, 72 patients were included. Most of them (69%) were hypoxemic and admitted for acute respiratory failure. No additional medication was needed in 96% of the patients. No severe side-effects occurred. Seventy-eight percent of patients described the procedure as “comfortable or very comfortable”. Physicians rated their comfort with a median [IQR] score of 9 [8–10].

Conclusion

Remifentanil target-controlled infusion administered to perform awake fiberoptic bronchoscopy in critically ill patients is feasible without requirement of additional analgesics or sedative drugs. Clinical tolerance as well as patients’ and operators’ comfort were good to excellent. This technique could benefit patients’ experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00832-6.

Morpho-functional evaluation of lung aeration as a marker of sickle-cell acute chest syndrome severity in the ICU: a prospective cohort study

Background

Acute chest syndrome (ACS) is the main cause of morbi-mortality in patients with sickle-cell disease in the intensive care unit (ICU). ACS definition encompasses many types of lung damage, making early detection of the most severe forms challenging. We aimed to describe ACS-related lung ultrasound (LU) patterns and determine LU performance to assess ACS outcome.

Results

We performed a prospective cohort study including 56 ICU patients hospitalized for ACS in a tertiary university hospital (Paris, France). LU and bedside spirometry were performed at admission (D0) and after 48 h (D2). Complicated outcome was defined by the need for transfusion of ≥ 3 red blood cell units, mechanical ventilation, ICU length-of-stay > 5 days, or death. A severe loss of lung aeration was observed in all patients, predominantly in inferior lobes, and was associated with decreased vital capacity (22 [15–33]% of predicted). The LU Score was 24 [20–28] on D0 and 20 [15–24] on D2. Twenty-five percent of patients (14/56) had a complicated outcome. Neither oxygen supply, pain score, haemoglobin, LDH and bilirubin values at D0; nor their change at D2, differed regarding patient outcome. Conversely, LU re-aeration score and spirometry change at D2 improved significantly more in patients with a favourable outcome. A negative LU re-aeration score at D2 was an independent marker of severity of ACS in ICU.

Conclusions

ACS is associated with severe loss of lung aeration, whose resolution is associated with favourable outcome. Serial bedside LU may accurately and early identify ACS patients at risk of complicated outcome.

Universal versus targeted additional contact precautions for multidrug-resistant organism carriage for patients admitted to an intensive care unit

BACKGROUND

Although additional contact precautions (ACPs) are routinely used to reduce cross-transmission of multidrug-resistant organisms (MDROs), the relevance of isolation precautions remains debated. We hypothesized that the collection of recognized risk factors for MDRO carriage on intensive care unit (ICU) admission might be helpful to target ACPs without increasing MDRO acquisition during ICU stays, compared with universal ACPs.

MATERIALS AND METHODS

This is a sequential single-center observational study performed in consecutive patients admitted to a French medical and surgical ICU. During the first 6-month period, screening for MDRO carriage and ACPs were performed in all patients. During the second 6-month period, screening was maintained, but ACP use was guided by the presence of at least 1 defined risk factor for MDRO.

RESULTS

During both periods, 33 (10%) and 30 (10%) among 327 and 297 admissions were, respectively, associated with a positive admission MDRO carriage. During both periods, a second screening was performed in 147 (45%) and 127 (43%) patients. Altogether, the rate of acquired MDRO (positive screening or clinical specimen) was similar during both periods (10% [n = 15] and 11.8% [n = 15], respectively; P = .66).

CONCLUSIONS

The results of our study contribute to support the safety of an isolation-targeted screening policy on ICU admission compared with universal screening and isolation regarding the rate of ICU-acquired MDRO colonization or infection.

The Challenging Diagnosis of Non-Community-Acquired Pneumonia in Non-Mechanically Ventilated Subjects: Value of Microbiological Investigation

BACKGROUND

Early recognition and an attempt at obtaining microbiological documentation are recommended in patients with non-community-acquired pneumonia (NCAP), whether hospital-acquired (HAP) or health care-associated (HCAP). We aimed to characterize the clinical features and microbial etiologies of NCAP to assess the impact of microbiological investigation on their management.

METHODS

This was a prospective 1-y study in a university hospital with 141 non-mechanically ventilated subjects suspected of having HAP (n = 110) or HCAP (n = 31).

RESULTS

Clinical criteria alone poorly identified pneumonia (misdiagnosis in 50% of cases). Microbiological confirmation was achievable in 80 subjects (57%). Among 79 microorganisms isolated, 28 were multidrug-resistant aerobic Gram-negative bacilli and group III Enterobacteriaceae and 6 were methicillin-resistant Staphylococcus aureus. Multidrug-resistant aerobic Gram-negative bacilli accounted for one third of the microorganisms in early-onset HAP and for 50% in late-onset HAP. Methicillin-resistant S. aureus was most often recovered from subjects with HCAP. Inappropriate empirical antibiotics were administered to 36% of subjects with confirmed pneumonia. Forty subjects were admitted to the ICU, 13 (33%) of whom died. Overall, 39 subjects (28%) died in the hospital.

CONCLUSIONS

Integrating the microbiological investigation in the complex clinical diagnostic workup of patients suspected of having NCAP is mandatory. Respiratory tract specimens should be obtained whenever possible for appropriate management.

Molecular characterization of DHA-1-producing Klebsiella pneumoniae isolates collected during a 4-year period in an intensive care unit

Seventeen Klebsiella pneumoniae isolates producing DHA-1 β-lactamase were collected in an intensive care unit between 2006 and 2010. Molecular analysis revealed the predominance of ST48 and ST1263 clones of K. pneumoniae and the spread of DHA-1-encoding plasmids belonging to incompatibility group IncL/M or IncHI2.

Risk and protective factors for major complications after pneumonectomy for lung cancer

Pneumonectomy carries a high-risk for postoperative complications. The aim of the study was to identify factors that may predispose to the development of major postoperative complications after pneumonectomy for lung cancer. All consecutive patients from January 2000 to December 2005 were retrospectively studied. Major postoperative complications were defined by respiratory failure, pulmonary embolism, pneumonia, shock, cardiogenic pulmonary oedema, myocardial ischaemia or symptomatic cardiac arrhythmia. One hundred and twenty-nine patients were included. The overall hospital mortality rate was 10.8%, and complications occurred in 42.6%. Multivariate analysis revealed that patients with American Society of Anesthesiologist (ASA) class >2 [odds ratio (OR) 8.26; 95% confidence interval (CI), 3.19-36.55] and liberal fluid administration during surgery (OR, 1.96 for each litre; 95% CI, 1.45-3.16) to be risk factor for major cardiopulmonary complication or mortality. Preoperative haemoglobin > or =10 g/dl (OR, 0.19; 95% CI, 0.01-0.91) and low tidal volume administrated during surgery (< or =7.35 ml/kg; OR, 0.36; 95% CI, 0.10-0.92) were identified as protective factors. Pneumonectomy remains a high-risk surgery. Postoperative complications may be influenced by the comorbidities but also the management of fluid infusion and mechanical ventilation during the surgical procedure.

Limitations of computed tomographic angiography in the diagnosis of brain death

OBJECTIVE

To evaluate the accuracy of cerebral computed tomographic angiography (CT-a) for the diagnosis of brain death (BD).

DESIGN AND SETTING

Prospective observational study in intensive care units.

PATIENTS

Twenty-one clinically BD patients enrolled over 12 months.

MEASUREMENTS AND RESULTS

All clinically BD patients were evaluated by electroencephalography (EEG) and CT-a after exclusion of hypothermia and drug intoxication. Data collected included: demographic characteristics, cause of BD, delay between in-hospital admission and BD diagnosis and between EEG and CT-a, occurrence of cardiac arrest, administration of vasoactive agents, results of EEG and CT-a. We evaluated the sensitivity of EEG and CT-a and their agreement. Groups were compared according to BD diagnosis by EEG and CT-a (E+C+), or only by EEG (E+C(-)). Statistical analysis were performed by Mann-Whitney test and Fisher's exact test. BD was confirmed by EEG in all cases (sensitivity 100%) whereas only 11 patients of 21 had no cerebral perfusion during CT-a (sensitivity 52.4%). No agreement was documented between EEG and CT-a for the diagnosis of BD (kappa = 0). Patients' characteristics did not differ between E+C+ and E+C(-) groups. In the E+C(-) group arterial opacification was observed in 100% of patients, but opacification of the internal cerebral veins was achieved in only 30%.

CONCLUSIONS

In clinically BD patients with no electroencephalographic activity CT-a documents opacification of the intracerebral vessels in a significant percentage of the cases. Therefore CT-a cannot be recommended as a means of BD diagnosis.

[ICU performance: results of a French study involving 80,000 ICU stays]

OBJECTIVE

The Standard Mortality Ratio (SMR), comparing the observed in-hospital mortality to the predicted, may measure the intensive care units (ICU) performance.

STUDY DESIGN

Multicentric retrospective national study.

METHODS

A probability model using a severity score such SAPS II calculated the predicted mortality rate. A national French study has been undertaken to compare the SMR of ICUs and looked for explanation.

RESULTS

One hundred six units, 34 were medical (32%), 18 surgical (17%) and 57 medical/surgical (51%) participated to the study. Forty-six ICUs (43%) were located in teaching hospitals. The SMR of the 87,099 stays was 0.84 (0.82-0.85). The SMR of ICUs varied from 0.41 to 1.55. Ten units had a SMR>0.85, which suggested a low performance. They had more stays for cardiovascular failures, as compared with others. The best units (SMR<0.82) had more stays for drug overdose. The SMR increased with the number of organ failures, from 0.47 with zero failure to 1.11 with 4 or more organ failures. The stays with cardiovascular failure, either unique or associated, had a higher SMR. The 7935 stays with a drug overdose had a SMR of 0.12 (0.10-0.14), which suggested a bad calibration of the model in theses cases.

CONCLUSION

The case mix must be taken in account when comparing the ICUs performance by the mean of SMR, particularly when the units admitted a lot of drug overdoses.

Diffuse large and small bowel necrosis in catastrophic antiphospholipid syndrome

The catastrophic variant is an accelerated form of the antiphospholipid syndrome resulting in multiorgan failure because of multiple small vessel occlusions. We report a case of catastrophic antiphospholipid syndrome in a patient with subacute cutaneous lupus erythematosus and ischemic bowel, who presented with acute abdominal pain due to diffuse right colon and small bowel necrosis requiring large resection, associated with acute respiratory distress syndrome, thrombocytopenia and disseminated intravascular coagulation. Histopathological examination of resected tissues showed diffuse arteriolar and venous thrombosis but no vasculitis, and mesenteric artery lumen severely narrowed by intimal fibrosis. The patient died 15 days after admission despite treatment with anticoagulation, steroids, continuous hemofiltration and plasma exchange. Ischemic bowel and diffuse intestinal necrosis may be secondary to the antiphospholipid syndrome, and a high level of suspicion and an early diagnosis are required.

Application of microsatellite typing for the investigation of a cluster of cases of Candida albicans candidaemia

A cluster of cases of Candida albicans candidaemia in a surgical intensive care unit was investigated. The probability of such a cluster during a single month was highly significant compared with the frequency of candidaemia in the previous year. A molecular typing method, based on length analysis of three (EF3, CDC3, HIS3) microsatellite-containing regions, was used to investigate isolates from patients in and outside the ward. This demonstrated the involvement of different strains, indicating the absence of cross-transmission among patients. Results of microsatellite typing can be obtained almost in real-time, which is particularly useful in an outbreak context.

[Completeness of ICU activity reports sent to French healthcare authorities]

INTRODUCTION

Hospital units report on their inpatient care activity by writing yearly activity reports, which are used by their Medical Information Department (MID) to develop standardized summaries for communication to healthcare authorities. The data are categorized by uniform patient groups and used to describe inpatient care activity and to guide resource allocation. The objective of this study was to evaluate the completeness of activity reports from intensive care units (ICUs) in France.

METHODS

Activity reports sent in 1998 and 1999 by French ICUs participating in the study were collected using dedicated abstracting software supplied to the relevant MIDs. Completeness of data in the activity reports was evaluated, with special attention to the SAPSII score, Omega rating of ICU procedures according to the Classification of Medical Procedures, and primary and secondary diagnoses.

RESULTS

The 106 ICUs that volunteered for the study reported data on 107,652-hospital stays. Mean age and SAPSII were 55 +/- 21 years and 35 +/- 21 years, respectively. Mean ICU and hospital lengths of stay were 6.2 +/- 12.4 and 16.1 +/- 21.6 days, respectively. Mean ICU and hospital mortality rates were 15% and 19%. The SAPSII and Omega procedures were reported for 81% and 80% of stays, respectively. The SAPSII and Omega procedures were calculated or coded in 94% (100/106) and 96% (102/106) of ICUs, respectively. Mean number of Omega procedures was 4.3+/-3.9. However, only 5% (5/106) of ICUs entered the SAPSII for every stay, and 21% (22/106) of ICUs failed to enter the SAPSII for over 20% of stays. Similarly, 53% (56/106) of ICUs rated no more than five Omega procedures on average per stay. The primary diagnosis was reported for all stays, and the mean number of secondary diagnoses was 3.5 +/- 3.8. In 80% (86/106) of ICUs, no more than five secondary diagnoses were coded on average per stay.

CONCLUSION

The analysis of this national database shows that data communicated to the MIDs and therefore to the healthcare authorities, are incomplete regarding SAPSII, ICU procedures, treatment intensity, and diagnoses. This may lead to the underestimation of ICU activity and resource needs, particularly if the SAPSII and selected procedures identified as markers for high-intensity critical care are used in the future.

[A new cause of postoperative confusion syndrome: nefopam]

We report a case of nefopam intoxication in a severely malnourished postoperative intensive care patient with profound hypoprotidemia. Nefopam induced agitation and confusion associated with anticholinergic symptoms such as tremor, hypertonia, mydriasis, and tachycardia. All these symptoms disappeared after withdrawal of the drug. Nefopam should be considered as a possible cause of confusion in postoperative patients.

[Is there an age limit for organ donors?]

Nowadays organ transplantations suffer from a lack of donors. Thus the waiting list of patients is constantly growing. Several ways to increase organ procurement are being evaluated. About 50% of cerebral deaths are related to vascular cerebral in patients older than 60 years. For the last few years, organs have been harvested from these patients despite their age. As the quality of the grafts is reduced, transplantation of one kidney may be insufficient whilst transplantation of the two kidneys to the same recipient is technically possible. We report here a case of a 44-year-old patient who was transplanted with two kidneys in September 2000. The donor was 85-year-old patient who died after prolonged cardiac arrest. Kidney biopsy showed a 16% rate of sclerotic glomeruli and mild interstitial fibrosis. The creatinine clearance estimated by the Cockcroft formula was 50 mL.min-1. The double kidney transplantation was successful, without any surgical or anaesthetic complication. Restoration of urine production was immediate. Three months after the transplantation, creatinine clearance was 80 mL.min-1. This observation gives the opportunity to discuss the criteria for organ harvesting in patients with cerebral death. Donor age should not remain anymore a systematic contra indication for kidney or liver donation. Renal function, macroscopic examination and histological findings seem more important for making a decision in taking the graft. Double transplantation, here the second case in France, has been performed for several years in other countries, and has permitted to expand the pool of donors, thus increasing the number of transplanted patients.

Effect of metformin on fatty acid and glucose metabolism in freshly isolated hepatocytes and on specific gene expression in cultured hepatocytes

The short-term effect of metformin on fatty acid and glucose metabolism was studied in freshly incubated hepatocytes from 24-hr starved rats. Metformin (5 or 50 mM) had no effect on oleate or octanoate oxidation rates (CO(2)+ acid-soluble products), whatever the concentration used. Similarly, metformin had no effect on oleate esterification (triglycerides and phospholipid synthesis) regardless of whether the hepatocytes were isolated from starved (low esterification rates) or fed rats (high esterification rates). In contrast, metformin markedly reduced the rates of glucose production from lactate/pyruvate, alanine, dihydroxyacetone, and galactose. Using crossover plot experiments, it was shown that the main effect of metformin on hepatic gluconeogenesis was located upstream of the formation of dihydroxyacetone phosphate. Increasing the time of exposure to metformin (24 hr instead of 1 hr) led to significant changes in the expression of genes involved in glucose and fatty acid metabolism. Indeed, when hepatocytes were cultured in the presence of 50 to 500 microM metformin, the expression of genes encoding regulatory proteins of fatty acid oxidation (carnitine palmitoyltransferase I), ketogenesis (mitochondrial hydroxymethylgltaryl-CoA synthase), and gluconeogenesis (glucose 6-phosphatase, phosphoenolpyruvate carboxykinase) was decreased by 30 to 60%, whereas expression of genes encoding regulatory proteins involved in glycolysis (glucokinase and liver-type pyruvate kinase) was increased by 250%. In conclusion, this work suggests that metformin could reduce hepatic glucose production through short-term (metabolic) and long-term (genic) effects.

[Interviews with families of organ donors: analysis of motivation for acceptance or refusal of donation]

OBJECTIVE

The reasons for organ donation acceptance or refusal are still unclear. This study analysed the influence of the circumstances of the conversations with the relatives of brain dead patients on their consent for organ donation.

STUDY DESIGN

Prospective study.

MATERIAL

The analysis included 41 questionnaires collected over nine months in one organ harvesting centre and focusing on the circumstances of death, the conditions of the conversations and the reasons for acceptance or refusal.

METHODS

Questionnaire filled in by the physicians after the interviews of the relatives of brain dead patients.

RESULTS

The refusal rate was higher (54 vs 21%) when only one physician participated in the conversation, when more than two relatives had to decide (42 vs 24%), when conversations took place during night or when the request for organ donation followed immediately the announcement of death (43 vs 20%). Most often the relatives gave their decision within minutes following the request.

CONCLUSION

The circumstances of conversation with families play an essential role in their decision-making. A written guideline implementation for these conversations would probably be beneficial for the decisions of families in favour of organ donation.

Clonidine does not impair redistribution hypothermia after the induction of anesthesia

Clonidine is commonly given for premedication, and it impairs normal thermoregulatory responses to warm and cold stimuli while depressing sympathetic tone. We studied the effect of premedication by clonidine on redistribution hypothermia induced by the induction of anesthesia. Sixteen ASA physical status I or II patients were randomly assigned to receive either clonidine 150 micrograms or a placebo. Anesthesia was induced 45 min later by thiopental, fentanyl, and vecuronium i.v. and was maintained by the administration of 0.6% isoflurane. We monitored central core (tympanic) temperature and skin surface temperatures at the forearm and the fingertip during the 2 h after the induction of anesthesia before surgery. We estimated skin blood flow at the level of the forearm by using laser Doppler during the same period. The core temperature decreased comparably in the two groups of patients, from 37.1 +/- 0.2 degrees C to 35.3 +/- 0.4 degrees C and from 37.1 +/- 0.2 degrees C to 35.5 +/- 0.3 degrees C in the clonidine and placebo groups, respectively. The forearm-fingertip surface temperature gradient decreased similarly in the two groups. There was no evidence of cutaneous vasoconstriction. The laser Doppler index at the fingertip increased similarly in the two groups, as did the forearm-fingertip temperature gradient. We conclude that premedication with clonidine does not significantly impair the profile of central hypothermia induced by heat redistribution after the induction of anesthesia.

IMPLICATIONS

The induction of general anesthesia is associated with redistribution hypothermia. This study shows that premedication with oral clonidine does not worsen the decrease in core temperature resulting from general anesthesia.

Troglitazone inhibits fatty acid oxidation and esterification, and gluconeogenesis in isolated hepatocytes from starved rats

The effects of troglitazone and pioglitazone on glucose and fatty acid metabolism were studied in hepatocytes isolated from 24-h-starved rats. These thiazolidinediones inhibited long-chain fatty acid (oleate) oxidation and produced a very oxidized mitochondrial redox state. By contrast, thiazolidinediones did not affect the rate of medium-chain fatty acid (octanoate) oxidation or the activity of mitochondrial carnitine palmitoyltransferase (CPT) I. Thiazolidinediones inhibited selectively triglyceride synthesis but not phospholipid synthesis. The combined inhibition of oleate oxidation and esterification by troglitazone was due to a noncompetitive inhibition of mitochondrial and microsomal long-chain acyl-CoA synthetase (ACS) activities. It was suggested that troglitazone must be metabolized into its sulfo-conjugate derivative in liver cells to inhibit mitochondrial and microsomal ACS activities. Thiazolidinediones inhibited glucose production from lactate/pyruvate or from alanine. Analysis of gluconeogenic metabolite concentrations suggested that troglitazone would inhibit gluconeogenesis at the level of pyruvate carboxylase and glyceraldehyde-3-phosphate dehydrogenase reactions. It was concluded that 1) at a similar concentration, troglitazone was more efficient than pioglitazone to inhibit fatty acid metabolism and gluconeogenesis and 2) the inhibition of gluconeogenesis by troglitazone could be the result of the inhibition of long-chain fatty acid oxidation (decrease in acetyl-CoA, NADH-to-NAD+, and ATP-to-ADP ratios).

Anaesthesia for caesarean section in a patient receiving high dose amiodarone for fetal supraventricular tachycardia

We report the anaesthetic management of a Caesarean section in a woman treated with high dose amiodarone for fetal supraventricular tachycardia. Most of the interactions between anaesthesia and amiodarone therapy previously reported were observed during general anaesthesia. We therefore chose epidural anaesthesia using incremental doses of lignocaine 2% with adrenaline and fentanyl. This technique appeared to be safe, but since severe refractory vasodilation with hypotension may occur, potent vasopressor agents should be immediately available.