Physiological predictors of respiratory and cough assistance needs after extubation.

BACKGROUND: Identifying patients at high risk of post-extubation acute respiratory failure requiring respiratory or mechanical cough assistance remains challenging. Here, our primary aim was to evaluate the accuracy of easily collected parameters obtained before or just after extubation in predicting the risk of post-extubation acute respiratory failure requiring, at best, noninvasive mechanical ventilation (NIV) and/or mechanical cough assistance and, at worst, reintubation after extubation. METHODS: We conducted a multicenter prospective, open-label, observational study from April 2012 through April 2015. Patients who passed a weaning test after at least 72 h of endotracheal mechanical ventilation (MV) were included. Just before extubation, spirometry and maximal pressures were measured by a technician. The results were not disclosed to the bedside physicians. Patients were followed until discharge or death. RESULTS: Among 3458 patients admitted to the ICU, 730 received endotracheal MV for longer than 72 h and were then extubated; among these, 130 were included. At inclusion, the 130 patients had mean ICU stay and endotracheal MV durations both equal to 11 ± 4.2 days. After extubation, 36 patients required curative NIV, 7 both curative NIV and mechanical cough assistance, and 8 only mechanical cough assistance; 6 patients, all of whom first received NIV, required reintubation within 48 h. The group that required NIV after extubation had a significantly higher proportion of patients with chronic respiratory disease (P = 0.015), longer endotracheal MV duration at inclusion, and lower Medical Research Council (MRC) score (P = 0.02, P = 0.01, and P = 0.004, respectively). By multivariate analysis, forced vital capacity (FVC) and peak cough expiratory flow (PCEF) were independently associated with (NIV) and/or mechanical cough assistance and/or reintubation after extubation. Areas under the ROC curves for pre-extubation PCEF and FVC were 0.71 and 0.76, respectively. CONCLUSION: In conclusion, FVC measured before extubation correlates closely with FVC after extubation and may serve as an objective predictor of post-extubation respiratory failure requiring NIV and/or mechanical cough assistance and/or reintubation in heterogeneous populations of medical ICU patients. ClinicalTrials.gov as #NCT01564745.

Sodium Bicarbonate Versus Sodium Chloride for Preventing Contrast-Associated Acute Kidney Injury in Critically Ill Patients: A Randomized Controlled Trial.

OBJECTIVES: To test whether hydration with bicarbonate rather than isotonic sodium chloride reduces the risk of contrast-associated acute kidney injury in critically ill patients. DESIGN: Prospective, double-blind, multicenter, randomized controlled study. SETTING: Three French ICUs. PATIENTS: Critically ill patients with stable renal function (n = 307) who received intravascular contrast media. INTERVENTIONS: Hydration with 0.9% sodium chloride or 1.4% sodium bicarbonate administered with the same infusion protocol: 3 mL/kg during 1 hour before and 1 mL/kg/hr during 6 hours after contrast medium exposure. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the development of contrast-associated acute kidney injury, as defined by the Acute Kidney Injury Network criteria, 72 hours after contrast exposure. Patients randomized to the bicarbonate group (n = 151) showed a higher urinary pH at the end of the infusion than patients randomized to the saline group (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.0001). The frequency of contrast-associated acute kidney injury was similar in both groups: 52 patients (33.3%) in the saline group and 53 patients (35.1%) in the bicarbonate group (absolute risk difference, -1.8%; 95% CI [-12.3% to 8.9%]; p = 0.81). The need for renal replacement therapy (five [3.2%] and six [3.9%] patients; p = 0.77), ICU length of stay (24.7 ± 22.9 and 23 ± 23.8 d; p = 0.52), and mortality (25 [16.0%] and 24 [15.9%] patients; p > 0.99) were also similar between the saline and bicarbonate groups, respectively. CONCLUSIONS: Except for urinary pH, none of the outcomes differed between the two groups. Among ICU patients with stable renal function, the benefit of using sodium bicarbonate rather than isotonic sodium chloride for preventing contrast-associated acute kidney injury is marginal, if any.

Fatal nosocomial meningitis caused by Mycoplasma hominis in an adult patient: case report and review of the literature.

Meningitis due to Mycoplasma hominis in adults is rarely described, with only three cases having been reported to date. A case of fatal meningitis in a 39-year-old patient after a neurosurgical procedure for a subarachnoid haemorrhage is reported herein. Identification and treatment were significantly delayed because of the rarity of the aetiology and difficulty identifying this organism with the routinely used conventional methods, such as Gram staining and agar growth on standard agar plates. Clinical procedures and the treatment of 'culture-negative' central nervous system infections is a real challenge for clinical microbiologists and clinicians, and M. hominis has to be considered as a potential, although very uncommon, pathogen.

Diagnostic accuracy of hemoconcentration for pulmonary edema as the cause of weaning failure.

BACKGROUND: Our objective was to assess the diagnostic accuracy of hemoconcentration for cardiogenic pulmonary edema (PE) as the cause of weaning failure, using left ventricular filling pressure elevation assessed by transthoracic echocardiography as the reference standard. METHODS: This prospective observational study included 41 patients who failed their first spontaneous breathing trial of weaning from mechanical ventilation. They were divided into two groups, with and without PE by echocardiographic criteria. Hemoconcentration and other hemodynamic parameters were compared between the groups. RESULTS: The group (N.=21) with PE by echocardiographic criteria had a higher frequency of failure of the second spontaneous breathing trial (P=0.03) and a longer total weaning time (P=0.02) compared to the other group. The receiver-operating characteristics curve indicated that changes in plasma protein or hemoglobin concentration from initiation to completion of the second spontaneous breathing trial did not predict PE as the cause of failure (areas under the receiver-operating characteristics curve, 0.47±0.09 and 0.51±0.09, respectively). The only factor predicting failure due to PE was a positive fluid balance from intensive care unit admission to study inclusion (P=0.01). The increase in mean arterial blood pressure seemed suggestive of weaning failure due to cardiac causes. CONCLUSIONS: Compared to echocardiographic criteria for left ventricular filling pressure elevation, hemoconcentration assessed based on plasma protein and hemoglobin levels did not help to diagnose cardiogenic PE as the cause of weaning failure.

Extracorporeal Life Support for Refractory Cardiac Arrest or Shock: A 10-Year Study.

We aimed to identify factors associated with hospital mortality among patients receiving extracorporeal life support (ECLS). All consecutive patients treated with ECLS for refractory cardiac arrest or shock in the Caen University Hospital in northwestern France during the last decade were included in a retrospective cohort study. Sixty-four patients were included: 29 with refractory cardiac arrest and 35 with refractory shock. The main reasons for ECLS were acute coronary syndrome (n = 23) and severe poisoning caused by drug intoxication (n = 19). At ECLS initiation, the left ventricular ejection fraction was 16% (±11). Initial blood test results were arterial pH = 7.19 (±0.20) and plasma lactate = 8.02 (±5.88) mmol/L. Forty (63%) patients died including 33 under ECLS. In a multivariate analysis, two factors were independently associated with survival: drug intoxication as the reason for ECLS (adjusted odds ratio [AOR], 0.07; 95% confidence intervals [CI], 0.01-0.28; p < 0.001) and arterial pH (an increase of 0.1 point [AOR, 0.013; 95% CI, <0.001-0.27; p < 0.01]). This study supports early ECLS as a last resort therapeutic option in a highly selected group of patients with refractory cardiac arrest or shock, in particular before profound acidosis occurs and when the cause is reversible.

Immature/total granulocyte ratio: a promising tool to assess the severity and the outcome of post-cardiac arrest syndrome.

BACKGROUND: The immature/total granulocyte (I/T-G) ratio increases during severe systemic inflammatory response syndrome. This study evaluated the I/T-G ratio as a predictor of poor outcome after out-of-hospital cardiac arrest (OHCA). METHODS: We conducted a pilot prospective cohort study of patients who were admitted in our intensive care unit (ICU) during a one-year period after post-OHCA resuscitation. I/T-G ratio measurements were obtained from blood samples collected on admission using flow cytometry and the outcomes were ICU mortality and post-cardiac arrest syndrome. RESULTS: Among the 130 patients (76% male, median age 54 [46-67] years), the median I/T-G ratio was 0.85 [0.42-1.98]%. The I/T-G ratio was poorly correlated with the SOFA score and lactate level on day 1 (r=0.25, p=0.005 and r=0.5, p<0.001, respectively). Patients with high I/T-G ratios were more likely to develop post-resuscitation shock (37% vs. 58%, p=0.02). Patients dying from post-resuscitation shock had a higher I/T-G ratio than patients dying from neurological causes (2 [1-4]% vs. 1.2 [0.6-1.2]%, p=0.02). The area under the ROC curve based on the I/T-G ratio was 0.82 for predicting ICU mortality. CONCLUSION: The I/T-G ratio appears to be an accurate predictor of poor outcome. However, the added clinical value of this marker and the possible involvement of immature granulocytes in the pathophysiology of post-cardiac arrest syndrome remain to be investigated.

Noninvasive ventilation and breathing-swallowing interplay in chronic obstructive pulmonary disease*.

OBJECTIVES: To investigate breathing-swallowing interactions in patients with chronic obstructive pulmonary disease requiring noninvasive mechanical ventilation and, if needed, to develop a technical modification of the ventilator designed to eliminate ventilator insufflations during swallowing. DESIGN: We conducted a prospective, open-label, interventional study. PATIENTS: Fifteen consecutive chronic obstructive pulmonary disease patients with exacerbations requiring ICU admission and NIV. INTERVENTIONS: Swallowing performance and breathing-swallowing interactions were investigated noninvasively by chin electromyography, cervical piezoelectric sensor, and inductive respiratory plethysmography. Two water-bolus sizes (5 and 10 mL) were tested in random order. Swallowing was tested with and without noninvasive mechanical ventilation, in random order. First, a standard mechanical ventilator capable of delivering noninvasive mechanical ventilation was used. Second, a marketed device was equipped with an off-switch for use during swallowing. MEASUREMENTS AND MAIN RESULTS: Swallowing performance and breathing-swallowing interactions were investigated noninvasively by chin electromyography, cervical piezoelectric sensor, and inductive respiratory plethysmography. Two water bolus sizes (5 and 10 mL) were tested in random order. Swallowing was tested with and without noninvasive mechanical ventilation in random order. First, a standard mechanical ventilator capable of delivering noninvasive mechanical ventilation was used. Swallowing efficiency, breathing-swallowing synchronization, and Borg Scale dyspnea scores improved significantly with noninvasive mechanical ventilation. However, swallowing induced ventilator triggering followed by autotriggering. To improve patient-ventilator synchrony, a marketed device was equipped with an off-switch for use during swallowing. This device completely eliminated swallowing-induced ventilator triggering and postswallow autotriggering. CONCLUSION: Patients with chronic obstructive pulmonary disease admitted to the ICU for acute exacerbations had abnormal breathing-swallowing interactions and dyspnea, which improved with noninvasive mechanical ventilation. Furthermore, a ventilator device with a simple switch-off pushbutton to eliminate insufflations during swallows prevented swallowing-induced ventilator triggering and postswallow autotriggering.

A comparison of survival with and without extracorporeal life support treatment for severe poisoning due to drug intoxication.

BACKGROUND: The use of extracorporeal life support (ECLS) as a treatment for severe cardiovascular impairment due to poisoning is unclear. Therefore, we conducted a retrospective cohort analysis to compare survival among critically ill poisoned patients treated with or without ECLS. METHODS: All consecutive patients admitted into 2 university hospitals in northwestern France over the past decade for persistent cardiac arrest or severe shock following poisoning due to drug intoxication were included. ECLS was preferentially performed in 1 of the 2 centers. RESULTS: Sixty-two patients (39 women, 23 men; mean age 48±17 years) fulfilled inclusion criteria: 10 with persistent cardiac arrest and 42 with severe shock. Fourteen patients were treated with ECLS and 48 patients with conventional therapies. All subjects received vasopressor and fluid loading. Patients treated with or without ECLS at ICU admission had comparable drug ingestion histories, Simplified Acute Physiology Score (SAPS II score) (66±18), Sequential Organ Failure Assessment (SOFA) score (median: 11 [IQR, 9-13]), Glasgow Coma Scale score (median: 3 [IQR, 3-11]), need for ventilator support (n=56) and extra renal support (n=23). Thirty-five (56%) patients survived: 12/14 (86%) ECLS patients and 23/48 (48%) non-ECLS patients (p=0.02, by Fisher exact test). None of the patients with persistent cardiac arrest survived without ECLS support. Based on admission data, beta-blocker intoxication (p=0.02) was also associated with lower mortality. In multivariate analysis, adjusting for SAPS II and beta-blocker intoxication, ECLS support remained associated with lower mortality [Adjusted Odds Ratio, 0.18; 95% CI, 0.03-0.96; p=0.04]. CONCLUSION: In the absence of response to conventional therapies, we consider that ECLS may improve survival in critically ill poisoned patients experiencing cardiac arrest and severe shock.