Oseltamivir Resistance in Severe Influenza A(H1N1)pdm09 Pneumonia and Acute Respiratory Distress Syndrome: A French Multicenter Observational Cohort Study.

In a multicenter cohort study including 22 oseltamivir-treated patients with influenza A(H1N1)pdm09 acute respiratory distress syndrome, prevalence of the H275Y substitution in the neuraminidase, responsible for highly reduced sensitivity to oseltamivir, was 23%. Patients infected with the H275Y mutant virus had higher day 28 mortality than others (80% vs 12%; P = .011).

Early severe digestive complications after lung transplantation.

OBJECTIVE: This study aimed to describe and to analyze early severe digestive complications (ESDC) after lung transplantation (LT) in our center. METHODS: A retrospective study included 351 patients, who underwent LT without cardiopulmonary bypass (CPB) at our center between March 1988 and December 2009. There were 86 double LTs and 265 single LTs. ESDCs were defined as complications (1) occurring during the first 30 days after transplantation or during initial hospitalization if longer; (2) involving the gastrointestinal tract; and (3) jeopardizing survival or requiring invasive therapeutic procedure. Patients' characteristics, associated risk factors, and influence of ESDC on early outcome have been analyzed. RESULTS: During the first 30 days after LT or initial hospitalization if longer, 26 ESDCs occurred in 26 patients (rate 7.4%, sex ratio M/F 66%, mean age 56 ± 6 years). This included 10 acute cholecystitis (38%), four angiocholitis (15%), three perforated gastroduodenal ulcers (11%), three digestive perforations (11%), two intestinal occlusions (8%), two mesenteric ischemia (8%), and two acute pancreatitis (8%). ESDC occurred after a mean postoperative follow-up of 14 days (5-46), required emergency surgical treatment in 20 cases (77%), significantly prolonged the mean duration of hospitalization (96 days with ESDC vs 55 days without ESDC, p < 0.0001), and was responsible for death in five cases (19%). Surgical treatment included cholecystectomy (n = 11), bowel resection (n = 3), ulcer surgery (n = 2), subtotal colectomy (n = 2), Hartmann procedure (n = 1), and open coelioscopy (n = 1). Age and bilateral LT were found to be significant risk factors for ESDC in both uni- and multivariate analyses. CONCLUSION: ESDC occurred in 7.4% of patients after LT without CPB, and was responsible for longer in-hospital stay. Relevant risk factors included older age and bilateral LT, interfering with current debate regarding recipients' selection and procedure's choice.

Restoring arterial pressure with norepinephrine improves muscle tissue oxygenation assessed by near-infrared spectroscopy in severely hypotensive septic patients.

PURPOSE: To examine the consequences of administration of norepinephrine on muscle tissue oxygenation in severely hypotensive septic shock patients. METHODS: This was a prospective observational study conducted in a medical intensive care unit of a university hospital. We included 28 septic shock patients that received early volume resuscitation. All were eligible for receiving norepinephrine because of life-threatening hypotension and low diastolic arterial pressure. Muscle tissue oxygen saturation (StO2) and its changes during a vascular occlusion test were measured at the level of the thenar eminence using a near-infrared spectroscopy (NIRS) device. Transpulmonary thermodilution cardiac index (CI) and NIRS-derived variables were obtained before and after the mean arterial pressure (MAP) was increased by norepinephrine. The baseline StO2 and the vascular occlusion test-derived variables of 17 healthy volunteers were measured and served as controls. RESULTS: In healthy volunteers, StO2 ranged between 75 and 90% and StO2 recovery slopes ranged between 1.5 and 3.4%/s. Administration of norepinephrine, which was associated with an increase in MAP from 54 ± 8 to 77 ± 9 mmHg (p < 0.05), also induced increases in CI from 3.14 ± 1.03 to 3.61 ± 1.28 L/min/m² (p < 0.05), in StO2 from 75 ± 9 to 78 ± 9% (p < 0.05) and in StO2 recovery slope from 1.0 ± 0.6 to 1.5 ± 0.7%/s (p < 0.05). CONCLUSIONS: Norepinephrine administration aimed at achieving a MAP higher than 65 mmHg in septic shock patients with life-threatening hypotension resulted in improvement of NIRS variables measured at the level of the thenar eminence.

Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients.

PURPOSE: To assess sublingual microcirculatory changes following passive leg raising (PLR) and volume expansion (VE) in septic patients. METHODS: This prospective study was conducted in two university hospital intensive care units and included 25 mechanically ventilated patients with severe sepsis or septic shock who were eligible for VE in the first 24 h of their admission. Pulse pressure variation (ΔPP), cardiac output (CO) and sublingual microcirculation indices were assessed at five consecutive steps: (1) semi-recumbent position (Baseline 1), (2) during PLR manoeuvre (PLR), (3) after returning to semi-recumbent position (Baseline 2), (4) at the time when VE induced the same degree of preload responsiveness as PLR (VE(∆PP = PLR)) and (5) at the end of VE (VE(END)). At each step, five sublingual microcirculation sequences were acquired using sidestream darkfield imaging to assess functional capillary density (FCD), microcirculatory flow index (MFI), proportion of perfused vessels (PPV) and flow heterogeneity index (FHI). RESULTS: The PLR, VE(∆PP = PLR) and VE(END) induced a significant increase in CO and a significant decrease in ΔPP compared to Baseline 1 and Baseline 2 values. Both PLR and VE induced significant increases in FCD, MFI and PPV and a significant decrease in FHI compared to Baseline 1 and Baseline 2 values. CONCLUSIONS: In preload responsive severe septic patients examined within the first 24 h of their admission, both PLR and VE improved sublingual microcirculatory perfusion. At the level of volume infusion used in this study, these changes in sublingual microcirculation were not explained by changes in rheologic factors or changes in arterial pressure.

Early administration of norepinephrine increases cardiac preload and cardiac output in septic patients with life-threatening hypotension.

INTRODUCTION: We sought to examine the cardiac consequences of early administration of norepinephrine in severely hypotensive sepsis patients hospitalized in a medical intensive care unit of a university hospital. METHODS: We included 105 septic-shock patients who already had received volume resuscitation. All received norepinephrine early because of life-threatening hypotension and the need to achieve a sufficient perfusion pressure rapidly and to maintain adequate flow. We analyzed the changes in transpulmonary thermodilution variables associated with the increase in mean arterial pressure (MAP) induced by norepinephrine when the achieved MAP was ≥65 mm Hg. RESULTS: Norepinephrine significantly increased MAP from 54 ± 8 to 76 ± 9 mm Hg, cardiac index (CI) from 3.2 ± 1.0 to 3.6 ± 1.1 L/min/m2, stroke volume index (SVI) from 34 ± 12 to 39 ± 13 ml/m2, global end-diastolic volume index (GEDVI) from 694 ± 148 to 742 ± 168 ml/m2, and cardiac function index (CFI) from 4.7 ± 1.5 to 5.0 ± 1.6 per min. Beneficial hemodynamic effects on CI, SVI, GEDVI, and CFI were observed in the group of 71 patients with a baseline echocardiographic left ventricular ejection fraction (LVEF) >45%, as well as in the group of 34 patients with a baseline LVEF ≤45%. No change in CI, SVI, GEDVI, or CFI was observed in the 17 patients with baseline LVEF ≤45% for whom values of MAP ≥75 mm Hg were achieved with norepinephrine. CONCLUSIONS: Early administration of norepinephrine aimed at rapidly achieving a sufficient perfusion pressure in severely hypotensive septic-shock patients is able to increase cardiac output through an increase in cardiac preload and cardiac contractility. This effect remained in patients with poor cardiac contractility except when values of MAP ≥75 mm Hg were achieved.