Left ventricular overloading identified by critical care echocardiography is key in weaning-induced pulmonary edema.

PURPOSE: To assess the role of left ventricular overload and cumulated fluid balance in the development weaning-induced pulmonary edema (WIPO). METHODS: Ventilated patients in sinus rhythm with COPD and/or heart failure (ejection fraction ≤ 40%) were studied. Echocardiography was performed immediately before and during a 30-min spontaneous breathing trial (SBT) using a T-tube. Patients who failed were treated according to echocardiography results before undergoing a second SBT. RESULTS: Twelve of 59 patients failed SBT, all of them developing WIPO. Patients who succeeded SBT had lower body weight (- 2.5 kg [- 4.8; - 1] vs. + 0.75 kg [- 2.95; + 5.57]: p = 0.02) and cumulative fluid balance (- 2326 ml [- 3715; + 863] vs. + 143 ml [- 2654; + 4434]: p = 0.007) than those who developed WIPO. SBT-induced central hemodynamic changes were more pronounced in patients who developed WIPO, with higher E wave velocity (122 cm/s [92; 159] vs. 93 cm/s [74; 109]: p = 0.017) and E/A ratio (2.1 [1.2; 3.6] vs. 0.9 [0.8; 1.4]: p = 0.001), and shorter E wave deceleration time (85 ms [72; 125] vs. 147 ms [103; 175]: p = 0.004). After echocardiography-guided treatment, all patients who failed the first SBT were successfully extubated. Fluid balance was then negative (- 2224 ml [- 7056; + 100] vs. + 146 ml [- 2654; + 4434]: p = 0.005). Left ventricular filling pressures were lower (E/E': 7.3 [5; 10.4] vs. 8.9 [5.9; 13.1]: p = 0.028); SBT-induced increase in E wave velocity (+ 10.6% [- 2.7/ + 18] vs. + 25.6% [+ 12.7/ + 49]: p = 0.037) and of mitral regurgitation area were significantly smaller. CONCLUSION: In high-risk patients, WIPO appears related to overloaded left ventricle associated with excessive fluid balance. SBT-induced central hemodynamic changes monitored by CCE help in guiding therapy for successful weaning.

Cardiovascular clusters in septic shock combining clinical and echocardiographic parameters: a post hoc analysis.

PURPOSE: Mechanisms of circulatory failure are complex and frequently intricate in septic shock. Better characterization could help to optimize hemodynamic support. METHODS: Two published prospective databases from 12 different ICUs including echocardiographic monitoring performed by a transesophageal route at the initial phase of septic shock were merged for post hoc analysis. Hierarchical clustering in a principal components approach was used to define cardiovascular phenotypes using clinical and echocardiographic parameters. Missing data were imputed. FINDINGS: A total of 360 patients (median age 64 [55; 74]) were included in the analysis. Five different clusters were defined: patients well resuscitated (cluster 1, n = 61, 16.9%) without left ventricular (LV) systolic dysfunction, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n = 64, 17.7%), patients with hyperkinetic profile (cluster 3, n = 84, 23.3%), patients with RV failure (cluster 4, n = 81, 22.5%) and patients with persistent hypovolemia (cluster 5, n = 70, 19.4%). Day 7 mortality was 9.8%, 32.8%, 8.3%, 27.2%, and 23.2%, while ICU mortality was 21.3%, 50.0%, 23.8%, 42.0%, and 38.6% in clusters 1, 2, 3, 4, and 5, respectively (p < 0.001 for both). CONCLUSION: Our clustering approach on a large population of septic shock patients, based on clinical and echocardiographic parameters, was able to characterize five different cardiovascular phenotypes. How this could help physicians to optimize hemodynamic support should be evaluated in the future.

Prognostic impact of left ventricular diastolic function in patients with septic shock.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is highly prevalent in the general population and associated with a significant morbidity and mortality. Its prognostic role in patients sustaining septic shock in the intensive care unit (ICU) remains controversial. Accordingly, we investigated whether LV diastolic function was independently associated with ICU mortality in a cohort of septic shock patients assessed using critical care echocardiography. METHODS: Over a 5-year period, patients hospitalized in a Medical-Surgical ICU who underwent an echocardiographic assessment with digitally stored images during the initial management of a septic shock were included in this retrospective single-center study. Off-line echocardiographic measurements were independently performed by an expert in critical care echocardiography who was unaware of patients' outcome. LV diastolic dysfunction was defined by the presence of a lateral E' maximal velocity <10 cm/s. A multivariate analysis was performed to determine independent risk factors associated with ICU mortality. RESULTS: Among the 540 patients hospitalized in the ICU with septic shock during the study period, 223 were studied (140 men [63 %]; age 64 ± 13 years; SAPS II 55 ± 18; SOFA 10 ± 3; Charlson 3.5 ± 2.5) and 204 of them (91 %) were mechanically ventilated. ICU mortality was 35 %. LV diastolic dysfunction was observed in 31 % of patients. The proportion of LV diastolic dysfunction tended to be higher in non-survivors than in their counterparts (28/78 [36 %] vs. 41/145 [28 %]: p = 0.15). Inappropriate initial antibiotic therapy (OR 4.17 [CI 95 % 1.33-12.5]: p = 0.03), maximal dose of vasopressors (OR 1.38 [CI 95 % 1.16-1.63]: p = 0.01), SOFA score (OR 1.16 [CI 95 % 1.02-1.32]: p = 0.02) and lateral E' maximal velocity (OR 1.12 [CI 95 % 1.01-1.24]: p = 0.02) were independently associated with ICU mortality. After adjusting for the SAPS II score, inappropriate initial antibiotic therapy and maximal dose of vasopressors remained independent factors for ICU mortality, whereas a trend was only observed for lateral E' maximal velocity (OR 1.11 [CI 95 % 0.99-1.23]: p = 0.07). CONCLUSION: The present study suggests that LV diastolic function might be associated with ICU mortality in patients with septic shock. A multicenter prospective study assessing a large cohort of patients using serial echocardiographic examinations remains required to confirm the prognostic value of LV diastolic dysfunction in septic shock.

Severe Rhabdomyolysis Associated with Staphylococcus aureus Acute Endocarditis Requiring Surgery.

BACKGROUND: Rhabdomyolysis has multiple etiologies with unclear mechanisms; however, rhabdomyolysis caused by Staphylococcus aureus infection is rare. CASE REPORT: A case report of severe rhabdomyolysis in a patient who presented with endocarditis caused by methicillin-susceptible S. aureus and review of relevant literature. RESULTS: The patient had a history of cardiac surgery for tetralogy of Fallot. He was admitted to the hospital because of fever and digestive symptoms. Respiratory and hemodynamic status deteriorated rapidly, leading to admission to the intensive care unit (ICU) for mechanical ventilation and vasopressor support. Laboratory tests disclosed severe rhabdomyolysis with a serum concentration of creatine kinase that peaked at 49,068 IU/L; all blood cultures grew methicillin-susceptible S. aureus. Antibiotic therapy was amoxicillin-clavulanic acid, ciprofloxacin, and gentamicin initially and was changed subsequently to oxacillin, clindamycin, and gentamicin. Transesophageal echocardiography showed vegetation on the pulmonary valve, thus confirming the diagnosis of acute endocarditis. Viral testing and computed tomography (CT) scan ruled out any obvious alternative etiology for rhabdomyolysis. Bacterial analysis did not reveal any specificity of the staphylococcal strain. The patient improved with antibiotics and was discharged from the ICU on day 26. He underwent redux surgery for valve replacement on day 53. CONCLUSIONS: Staphylococcal endocarditis should be suspected in cases of severe unexplained rhabdomyolysis with acute infectious symptoms.

Nicardipine-induced acute pulmonary edema: a rare but severe complication of tocolysis.

We report four cases of acute pulmonary edema that occurred during treatment by intravenous tocolysis using nicardipine in pregnancy patients with no previous heart problems. Clinical severity justified hospitalization in intensive care unit (ICU) each time. Acute dyspnea has begun at an average of 63 hours after initiation of treatment. For all patients, the first diagnosis suspected was pulmonary embolism. The patients' condition improved rapidly with appropriate diuretic treatment and by modifying the tocolysis. The use of intravenous nicardipine is widely used for tocolysis in France even if its prescription does not have a marketing authorization. The pathophysiological mechanisms of this complication remain unclear. The main reported risk factors are spontaneous preterm labor, multiple pregnancy, concomitant obstetrical disease, association with beta-agonists, and fetal lung maturation corticotherapy. A better knowledge of this rare but serious adverse event should improve the management of patients. Nifedipine or atosiban, the efficiency of which tocolysis was also studied, could be an alternative.

Prostatic abscesses and severe sepsis due to methicillin-susceptible Staphylococcus aureus producing Panton-Valentine leukocidin.

BACKGROUND: Prostatic abscesses are an uncommon disease usually caused by enterobacteria. They mostly occur in immunodeficient patients. It is thus extremely rare to have a Staphylococcal prostatic abscess in a young immunocompetent patient. CASE PRESENTATION: A 20-year-old patient was treated with ofloxacin for a suspicion of prostatitis. An ultrasonography was performed because of persisting symptoms and showed acute urinary retention and prostatic abscesses. So the empirical antibiotic therapy was modified with ceftriaxone/amikacin. The disease worsened to severe sepsis and the patient was admitted in ICU. CT-scan and MRI confirmed three abscesses with perirectal infiltration and the bacteriological samples (abscesses and blood cultures) were positive to methicillin-susceptible Staphylococcus aureus producing Panton-Valentine leukocidine. The treatment was changed with fosfomycin/ofloxacin which resulted in a general improvement and the regression of the abscesses. CONCLUSION: Staphyloccocus aureus producing Panton-Valentine leukocidin are most commonly responsible for skin and soft tissue infections. To this day, no other case of prostatic abscess due to this strain but susceptible to methicillin has been described.