High veno-arterial carbon dioxide gradient is not predictive of worst outcome after an elective cardiac surgery: a retrospective cohort study.

Alteration of tissue perfusion is a main contributor of organ dysfunction. In cardiac surgery, the importance of organ dysfunction is associated with worse outcome. Central venous-arterial difference in CO2 tension (ΔCO2) has been proposed as a global marker of the adequacy of tissue perfusion in shock states. We hypothesized that ΔCO2 could be increased in case of postoperative organ failure or worse outcome. In this monocentric retrospective cohort study, we retrieved, from our database, 220 consecutive patients admitted in intensive care after an elective cardiac surgery. Four time points were formed: ICU admission, and 6, 24 and 48 h after. A ΔCO2 below 6 mmHg defined the normal range values. The SOFA score, intensive care unit and hospital length of stay, hospital and 6-month mortality rate were recorded. We compared patient with low ΔCO2 (<6 mmHg) and high ΔCO2 (≥6 mmHg). We included 55 (25 %) and 165 patients in low and high ΔCO2 groups, respectively. The SOFA score, the hospital and 6 months mortality rate were higher in patients with low ΔCO2. Surprisingly, we did not find results previously published in other surgical settings. In cardiac surgery, ΔCO2 has a low predictive value of outcome.

Transcranial Color Duplex Ultrasound: A Reliable Tool for Cerebral Hemodynamic Assessment in Brain Injuries.

BACKGROUND: Transcranial color duplex ultrasound (TCCD) is becoming an important tool for cerebral monitoring of brain-injured patients. To date, TCCD reproducibility has been studied in healthy volunteers or patients with subarachnoid hemorrhage and its efficiency in many brain injuries has not been proved. Our aim was to evaluate TCCD interobserver agreement in different brain injuries. PATIENTS AND METHODS: We performed a prospective monocentric trial conducted from January 2014 to September 2014 in intensive care unit (ICU) of Saint-Etienne university teaching hospital, France.Brain-damaged patients admitted in ICU were included, excluding those with decompressive craniectomy. Two randomized operators among the ICU medical staff consecutively performed measurements of cerebral blood flow velocities with TCCD. RESULTS: One hundred measurements were obtained from 42 patients. Hemodynamic and end-tidal CO2 pressure were similar between both measurement set. The results obtained with the Bland-Altman method showed bias at 0.52 (95% confidence interval [CI], -4.19 to 3.16), 0.53 (95% CI, -1.86 to 2.92), and 0.002 (95% CI, -0.06 to 0.06) for mean velocity, diastolic velocity, and pulsatility index, respectively. The limits of agreement were (-32.4; 31.4), (-20.4; 21.4), (-0.5; 0.5) for mean velocity, diastolic velocity, and pulsatility index, respectively. The Passing and Bablok regression have shown a quasilinear relationship between measurements. CONCLUSIONS: We reported the reliability of TCCD interobserver agreement in brain-damaged patients.

Severe rhabdomyolysis associated with a primary cytomegalovirus infection in an immunocompetent patient.

Virus-induced rhabdomyolysis rarely induces respiratory failure. We discuss here a case of severe rhabdomyolysis with acute respiratory failure secondary to a cytomegalovirus (CMV) primary infection. We report a case of severe acute rhabdomyolysis, leading to respiratory failure and mechanical ventilation, associated with CMV primary infection in a young and otherwise healthy woman. We excluded other aetiologies such as metabolic myopathies, electrolyte disorders or Guillain-Barré syndrome with exhaustive researches. After 1 year, the patient recovered completely, apart from a slight muscle deconditioning. In this report, we compare our patient with five other similar cases found in the literature; our patient had the most severe presentation. The mechanism of acute viral-induced rhabdomyolysis remains elusive.

De-escalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a medico-surgical intensive care unit.

INTRODUCTION: Most data on de-escalation of empirical antimicrobial therapy has focused on ventilator-associated pneumonia. In this retrospective monocentric study, we evaluated de-escalation as part of a global strategy of empiric antibiotherapy management irrespective of the location and the severity of the infection. The goal of this trial was to assess the application of a de-escalation strategy and the impact in terms of re-escalation, recurrent infection and to identify variables associated with de-escalation. METHODS: All consecutive patients treated with empiric antibiotic therapy and hospitalized in the intensive care unit for at least 72 hours within a period of 16 months were included. We compared the characteristics and outcome of patients who have experienced de-escalation therapy with those who have not. RESULTS: A total of 116 patients were studied corresponding to 133 infections. Antibiotic therapy was de-escalated in 60 cases (45%). De-escalation, primarily accomplished by a reduction in the number of antibiotics used, was observed in 52% of severe sepsis or septic shock patients. Adequate empiric antibiotic and use of aminoglycoside were independently linked with de-escalation. De-escalation therapy was associated with a significant reduction of recurrent infection (19% vs 5% P = 0.01). Mortality was not changed by de-escalation. CONCLUSIONS: As part of a global management of empiric antibiotherapy in an intensive care unit, de-escalation might be safe and feasible in a large proportion of patients.

Prospective determination of serum ceftazidime concentrations in intensive care units.

INTRODUCTION: The purpose of this study was to assess the value of a serum assay for ceftazidime (CAZ) in patients in the intensive care unit (ICU) of the Saint-Etienne University Teaching Hospital and in other ICUs in the region to optimize therapy. MATERIAL AND METHODS: Between November 1, 2005, and February 29, 2008, for patients hospitalized in ICUs not on dialysis and undergoing continuous CAZ infusion, serum assay of the antibiotic was performed 36 to 48 hours after the start of treatment using a single serum sample. The target serum CAZ concentration was 40 +/- 10 mg/L with a concentration/minimum inhibitory concentration ratio of 5 or greater x minimum inhibitory concentration of CAZ when a strain was isolated. RESULTS: Serum CAZ concentration was determined in 92 patients (28 females, 64 males) receiving CAZ by continuous infusion. The mean age was 66 years (range, 19-89 years) and the mean weight was 73 kg (range, 33-122 kg). The CAZ dose was between 1 g and 6 g/24 hours. The mean serum CAZ concentration was 46.9 mg/L (range, 7.4-162.3 mg/L). Serum CAZ concentrations were as follows: 30 to 50 mg/L in 35.9% of patients, less than 30 mg/L in 36.9%, and greater than 50 mg/L in 27.2%. Infection was documented in 51 patients, with 42 strains of Pseudomonas aeruginosa being detected. The serum concentration/minimum inhibitory concentration ratio was 5 or greater for 84.3%. Antibiotic dosage was adjusted based on the CAZ assay results. CONCLUSION: Our study suggests that CAZ measurement is needed in ICUs to achieve adequate CAZ concentrations to avoid treatment toxicity and to achieve efficacy as rapidly as possible, particularly in strains having limited susceptibility to antibiotics.

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.

Conversion of prevalence survey data on nosocomial infections to incidence estimates: a simplified tool for surveillance?

We calculated the incidence of nosocomial infection in 2 intensive care units (ICUs) on the basis of prevalence data recorded from 1997 through 2002 and compared these estimates to cumulative incidences measured in the 2 ICUs during the same period to investigate the feasibility and the reliability of converting prevalence data to incidence estimates. Decreases in the calculated and measured incidences over time in the ICUs were found to be statistically significantly related.

Do antifibrinolytics reduce allogeneic blood transfusion in orthopedic surgery?

Studies have shown that antifibrinolytic (aprotinin, tranexamic acid, epsilon-aminocaproic acid) reduce blood loss in orthopedic surgery. However, most lacked sufficient power to evaluate the efficacy and safety on clinical outcomes. This meta-analysis aims to evaluate whether intravenous antifibrinolytics, when compared with placebo, reduce perioperative allogeneic erythrocyte transfusion requirement in adults undergoing orthopedic surgery and whether it might increase the risk of venous thromboembolism. From MEDLINE, EMBASE, and the Cochrane Controlled Trials Register, the authors identified 43 randomized controlled trials in total hip and knee arthroplasty, spine fusion, musculoskeletal sepsis, or tumor surgery performed to July 2005 (for aprotinin, 23 trials with 1,268 participants; tranexamic acid, 20 with 1,084; epsilon-aminocaproic acid, 4 with 171). Aprotinin and tranexamic acid reduced significantly the proportion of patients requiring allogeneic erythrocyte transfusion according to a transfusion protocol. The odds ratio was 0.43 (95% confidence interval, 0.28-0.64) for aprotinin and 0.17 (0.11-0.24) for tranexamic acid. Results suggest a dose-effect relation with tranexamic acid. Epsilon-aminocaproic acid was not efficacious. Unfortunately, data were too limited for any conclusions regarding safety. Although the results suggest that aprotinin and tranexamic acid significantly reduce allogeneic erythrocyte transfusion, further evaluation of safety is required before recommending the use of antifibrinolytics in orthopedic surgery.

Preoperative peribulbar block in patients undergoing retinal detachment surgery under general anesthesia: a randomized double-blind study.

Retinal detachment surgery is frequently associated with significant postoperative pain and emesis in adults. In this randomized, double-blind, controlled study we sought to demonstrate that 1% ropivacaine peribulbar (PB) block in conjunction with general anesthesia (GA) improves operative conditions and postoperative analgesia compared with GA combined with subcutaneous normal saline injection into the inferior eyelid. Thirty-one patients were included in each group. Anesthesia was performed with target-controlled infusion propofol and continuous remifentanil infusion adjusted to maintain bispectral index values between 40 and 50. Postoperative analgesia included fixed-dose IV infusion of propacetamol and IV injection of nefopam via a patient-controlled analgesia device. Tramadol was infused IV as rescue medication. Demographic data were comparable between the groups and bispectral index values were maintained at the objective target. In the PB group, fewer patients presented an oculocardiac reflex (6 versus 17; P < 0.01); bleeding interfering with the surgical field was reduced (1 versus 11 patients; P < 0.01); mean time to first nefopam request was longer (148 +/- 99 versus 46 +/- 58 min; P < 0.01); mean nefopam consumption was diminished during the first 6 h after tracheal extubation (18.9 +/- 13.9 versus 28.5 +/- 14.7 mg; P < 0.05); immediate postoperative pain scores were lower; and fewer patients required rescue medication (5 versus 23; P < 0.01). The two groups were similar with respect to the incidence of postoperative nausea and vomiting. Overall, PB block combined with GA improved operating conditions and postoperative analgesia in retinal detachment surgery.

Candida as a risk factor for mortality in peritonitis.

OBJECTIVE: The clinical significance of Candida cultured from peritoneal fluid specimens remains a matter of debate. None of the studies that have addressed this issue have clearly distinguished between community-acquired peritonitis and nosocomial peritonitis. The current study tried to differentiate the pathogenic role of Candida in these two clinical settings and assess its importance on outcome. DESIGN: A multiple-center, retrospective, case-control study was conducted in intensive care unit patients. The interaction between mortality rates and type of patients was assessed. In the case of a significant interaction, a separate analysis of mortality and morbidity was planned. SETTING: Seventeen intensive care units in teaching and nonteaching hospitals. PATIENTS: Cases were patients operated on for peritonitis with Candida cultured from the peritoneal fluid, whereas controls were operated patients free from yeast. Cases and controls were matched for type of infection, Simplified Acute Physiology Score II, age, and time period of hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The following characteristics were collected: demographic variables, underlying disease, severity score, site of infection, microbiological features, and anti-infective treatments. Survival was defined as the main outcome criterion and morbidity variables as secondary criteria. Odds ratios of mortality were calculated. Matching was achieved in 91 cases and 168 controls. Matching criteria, clinical characteristics, and mortality rate were not statistically different between cases and controls. A significant interaction was demonstrated between mortality rates and type of infection, leading to separate analysis of patients with community-acquired peritonitis and nosocomial peritonitis. The subgroup analysis demonstrated an increased mortality rate only in nosocomial peritonitis with fungal isolates (48% vs. 28% in controls, p<.01). Upper gastrointestinal tract site (odds ratio, 4.9; 95% confidence interval, 1.6-14.8) and isolation of Candida species (odds ratio, 3.0; 95% confidence interval, 1.3-6.7, p<.001) were found to be independent risk factors of mortality in nosocomial peritonitis patients. CONCLUSIONS: Isolation of Candida species appears to be an independent risk factor of mortality in nosocomial peritonitis but not in community-acquired peritonitis.

A comparison of target- and manually controlled infusion propofol and etomidate/desflurane anesthesia in elderly patients undergoing hip fracture surgery.

Elderly patients have a higher risk of developing adverse drug reactions during anesthesia, especially anesthesia affecting cardiovascular performance. In this prospective randomized study we compared quality of induction, hemodynamics, and recovery in elderly patients scheduled for hip fracture surgery and receiving either etomidate/desflurane (ETO/DES) or target-controlled (TCI) or manually controlled (MAN) propofol infusion for anesthesia. Sixteen patients were anesthetized with ETO (0.4 mg/kg) followed by DES titrated from an initial end-tidal concentration of 2.5%. Eighteen patients received propofol TCI at an initial plasma concentration of 1 microg/mL and titrated upwards by 0.5-microg/mL steps. Fifteen patients received a bolus induction of propofol 1 mg/kg over 60 s followed by an infusion initially set at 5 mg . kg(-1) . h(-1). All received a bolus (20 microg/kg) followed by an infusion of 0.4 microg . kg(-1) . min(-1) alfentanil. According to hemodynamics, concentrations of DES or propofol (TCI group) and propofol infusion rate (MAN group) were respectively adjusted by a step of 20% and 50%. In the TCI and ETO/DES groups, the time spent at a mean arterial blood pressure within 15% and 30% of baseline values was more than 60% and 80% of anesthesia time, whereas in the MAN group it was <30% and 60%, respectively. In the MAN group more anesthetic drug adjustments were recorded (6.4 +/- 2.8 versus 2.5 +/- 1.2 [ETO/DES] and 2.6 +/- 1 [TCI]). TCI improves the time course of propofol's hemodynamic effects in elderly patients.

Optimal low-molecular-weight heparin regimen in major orthopaedic surgery. A meta-analysis of randomised trials.

Low-molecular-weight heparins (LMWH) are routinely used for thromboprophylaxis in major lower limb orthopaedic surgery. However the optimal LMWH regimen, offering the greatest efficacy with an acceptable risk of bleeding, has not been clearly established with regard to dose and timing of treatment initiation. We performed a meta-analysis of all available randomised trials comparing LMWH to placebo. Relative risks (RR) and corresponding 95% confidence intervals (CI) were calculated. By means of subgroup analysis, we evaluated the consistency of the results according to the timing of treatment initiation (preoperative versus postoperative) and dose of LMWH used (low doses, i.e. 4000 anti-Xa IU or below versus high doses). The possibility of a dose-effect relationship of LMWH was also evaluated by meta-regression. Thirteen studies were included (1925 patients). In four studies, LMWH treatment was started postoperatively. Daily LMWH doses ranged from 3000 anti-Xa IU to over 6000 anti-Xa IU. Compared to placebo, LMWH significantly reduced the risk of asymptomatic deep-vein thrombosis (DVT) (RR=0.51, 95% CI=[0.45-0.59], p<0.001) without significantly increasing the risk of major haemorrhage (RR=0.80 [0.36-1.79], p=0.58). We found no convincing evidence that starting prophylaxis preoperatively was associated with a significantly reduced risk of asymptomatic DVT relative to starting postoperatively. Our results showed a strong correlation between the risk of DVT and LMWH dose (meta-regression, test of slope p=0.03). These findings are tentative because the comparisons are across trials, but nevertheless suggest that the different LMWH regimens currently recommended are effective and safe.

Target-controlled versus manually-controlled infusion of propofol for direct laryngoscopy and bronchoscopy.

UNLABELLED: Few studies have compared the clinical profile of target-controlled infusions of propofol with that of manually-controlled infusions. Fifty-four ASA physical status I or II patients scheduled for an elective otorhinolaryngology endoscopy performed under general anesthesia with spontaneous ventilation were enrolled in this prospective randomized study to compare the clinical outcome of such administrations. Before induction, all patients received a single alfentanil bolus dose (10 microg/kg). Propofol administration was adapted to maintain absence of movement, hemodynamic stability, and efficient spontaneous ventilation. When compared with the Manually-Controlled Infusion group, in the Target-Controlled Infusion group there were fewer movements at insertion of the laryngoscope (14.8% vs. 44.4%), improved hemodynamic stability (largest variations of mean arterial blood pressure <10% of control values, versus 20%), fewer episodes of apnea, and less respiratory acidosis after endoscopy (pH = 7.37 +/- 0.05 and PaCO(2) = 50 +/- 7 mm Hg versus pH = 7.28 +/- 0.06 and PaCO(2) = 58 +/- 9 mm Hg); the recovery was also shorter (time to opening eyes or verbal response, 4.6 +/- 2.0 min and 6.8 +/- 2.5 min versus 10.8 +/- 7.3 min and 15.7 +/- 7.1 min). Propofol consumption was comparable in the two groups. Targeting the effect-site concentration improved the time course of the propofol drug effect during direct laryngoscopy performed during spontaneous ventilation when compared with manual infusion. IMPLICATIONS: This study compares the clinical profile of propofol anesthesia for direct laryngoscopy with spontaneous ventilation when the drug is administered either as a manually controlled infusion or by targeting the effect-site concentration through a target-controlled infusion (TCI) device. TCI improves the time course of propofol effects.

Diagnostic and therapeutic management of nosocomial pneumonia in surgical patients: results of the Eole study.

OBJECTIVE: To assess clinical, microbiological, and therapeutic features of nosocomial pneumonias in surgical patients. DESIGN: Prospective (October 1997 through May 1998), consecutive case series analysis of patients suspected of having pneumonia during the fortnight after a surgical procedure or trauma and receiving antibiotic therapy prescribed by the attending physician for this diagnosis. SETTING: A total of 230 study centers in teaching (n = 66) and nonteaching hospitals (n = 164) (surgical wards and intensive care units). PATIENTS: A total of 837 evaluable patients (mean age 61 +/- 18 yrs) including 629 intensive care unit patients. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The diagnostic and therapeutic procedures followed were based on guidelines. Antibiotics and any changes of therapy and duration of treatment were decided by the attending physician. The charts were reviewed by a panel of experts that classified the cases according to clinical, radiologic, and microbiological criteria (when available). The efficacy of treatment was evaluated over a 30-day period following the index episode. The patients were classified into three groups: definite pneumonia (n = 261), possible pneumonia (n = 392), or low-probability pneumonia (n = 184). Ventilator-acquired pneumonia was reported in 303 patients. Early onset pneumonia was reported in 512 cases. Microbiological sampling was performed in 718 patients, by bronchoscopy in 367 cases, recovering 450 organisms in 328 patients, including 94 polymicrobial specimens. High proportions of Gram-negative bacteria and staphylococci were cultured, even in early onset pneumonias. Antibiotic therapy was administered for 13 +/- 4 days, using monotherapy in 254 cases. Changes in the initial antibiotic therapy (135 monotherapies) were decided in 517 patients (including clinical failure or persistent infection, n = 171; organisms resistant to initial therapy, n = 177; pulmonary superinfection, n = 68). Death occurred in 180 patients, related to pneumonia in 53 cases. CONCLUSIONS: Nosocomial pneumonias in surgical patients are characterized by high frequency of early onset pneumonia, high proportion of nosocomial organisms even in these early onset pneumonias, and moderate mortality rate.