Thromboembolic events after major bleeding events in patients with mechanical heart valves: a 13-year analysis.

Anticoagulation in patients with mechanical heart valves (MHV) is associated with a risk of major bleeding episodes (MBE). In case of MBE, anticoagulant interruption is advocated. However, there is lack of data regarding the thrombo-embolic events (TE) risk associated with anticoagulant interruption. The main objective of the study was to evaluate the rate and risk factors of 6-months of TEs in patients with MHV experiencing MBE. This observational study was conducted over a 13-year period. Adult patients with a MHV presenting with a MBE were included. The main study endpoint was 6-month TEs, defined by clinical TEs or an echocardiographic documented thrombosis, occurring during an ICU stay or within 6-months. Thromboembolic events were recorded at ICU discharge, and 6 months after discharge. Seventy-nine MBEs were analysed, the rate of TEs at 6-months was 19% CI [11-29%]. The only difference of presentation and management between 6-month TEs and free-TE patients was the time without effective anticoagulation (TWA). The Receiver Operator Characteristic curve identified the value of 122 h of TWA as a cut-off. The multivariate analysis identified early bleeding recurrences (OR 3.62, 95% CI [1.07-12.25], p = 0.039), and TWA longer than 122 h (OR 4.24, 95% CI [1.24-14.5], p = 0.021), as independent risk factors for 6-month TEs. A higher rate of TE was associated with anticoagulation interruption longer than 5 days and early bleeding recurrences. However, the management should still be personalized and discussed for each case given the heterogeneity of causes of MBE and possibilities of haemostatic procedures.

Microbiological profile of patients treated for postoperative peritonitis: temporal trends 1999-2019.

BACKGROUND: Temporal changes in the microbiological resistance profile have been reported in several life-threatening infections. However, no data have ever assessed this issue in postoperative peritonitis (POP). Our purpose was to assess the rate of multidrug-resistant organisms (MDROs) in POP over a two-decade period and to analyse their influence on the adequacy of empirical antibiotic therapy (EAT). METHODS: This retrospective monocentric analysis (1999-2019) addressed the changes over time in microbiologic data, including the emergence of MDROs and the adequacy of EAT for all intensive care unit adult patients treated for POP. The in vitro activities of 10 antibiotics were assessed to determine the most adequate EAT in the largest number of cases among 17 antibiotic regimens in patients with/without MDRO isolates. Our primary endpoint was to determine the frequency of MDRO and their temporal changes. Our second endpoint assessed the impact of MDROs on the adequacy of EAT per patient and their temporal changes based on susceptibility testing. In this analysis, the subgroup of patients with MDRO was compared with the subgroup of patients free of MDRO. RESULTS: A total of 1,318 microorganisms were cultured from 422 patients, including 188 (45%) patients harbouring MDROs. The growing proportions of MDR Enterobacterales were observed over time (p = 0.016), including ESBL-producing strains (p = 0.0013), mainly related to Klebsiella spp (p < 0.001). Adequacy of EAT was achieved in 305 (73%) patients. Decreased adequacy rates were observed when MDROs were cultured [p = 0.0001 vs. MDRO-free patients]. Over the study period, decreased adequacy rates were reported for patients receiving piperacillin/tazobactam in monotherapy or combined with vancomycin and imipenem/cilastatin combined with vancomycin (p < 0.01 in the three cases). In patients with MDROs, the combination of imipenem/cilastatin + vancomycin + amikacin or ciprofloxacin reached the highest adequacy rates (95% and 91%, respectively) and remained unchanged over time. CONCLUSIONS: We observed high proportions of MDRO in patients treated for POP associated with increasing proportions of MDR Enterobacterales over time. High adequacy rates were only achieved in antibiotic combinations involving carbapenems and vancomycin, while piperacillin/tazobactam is no longer a drug of choice for EAT in POP in infections involving MDRO.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study.

BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

Serum lactate and acute mesenteric ischaemia: An observational, controlled multicentre study.

BACKGROUND: Early diagnosis and prompt management of acute mesenteric ischaemia (AMI) are key to survival but remain extremely difficult, due to vague and non-specific symptoms. Serum lactate (SL) is commonly presented as a useful biomarker for the diagnosis or prognosis of AMI. The aim of our study was test SL (1) as a diagnostic marker and (2) as a prognostic marker for AMI. STUDY DESIGN: This was an ancillary multicentre case-control study. Patients with AMI at intensive care unit (ICU) admission were included (AMI group) and matched to ICU patients without AMI (control group). SL was measured and compared on day 0 (D0) and day 1 (D1). Diagnosis and prognosis accuracy were assessed by receiver operating characteristic (ROC) and their area under the curve (AUC). RESULTS: Each group consisted of 137 matched ICU patients. There was no significant difference of SL between the two groups at D0 or at D1 (p = 0.26 and p = 0.29 respectively). SL was a poor marker of AMI: at D0 and D1, AUC were respectively 0.57 [0.51; 0.63] and 0.60 [0.53; 0.67]. SL at D0 and D1 correctly predicted ICU mortality, independently of AMI (AUC D0: 0.69 [0.59; 0.79] vs. 0.74 [0.65; 0.82]; p = 0.51 and D1: 0.74 [0.64; 0.84] vs. 0.76 [0.66; 0.87]; p = 0.77, respectively, for control and AMI groups]. CONCLUSIONS: SL has no specific link with AMI, both for diagnosis and prognosis. SL should not be used for the diagnosis of AMI but, despite its lack of specificity, it may help to assess severity.

Relationship between liver dysfunction, lipoprotein concentration and mortality during sepsis.

BACKGROUND: High-density lipoproteins (HDLs) are synthesized by the liver and display endothelioprotective properties, including anti-inflammatory, antiapoptotic, antithrombotic and antioxidant effects. In both septic and chronic liver failure patients, a low HDL cholesterol (HDL-C) concentration is associated with overmortality. Whereas sepsis-associated liver dysfunction is poorly defined, the aim of this study was to characterize the relationship between liver dysfunction, lipoprotein concentrations and mortality in septic patients in the intensive care unit (ICU). METHODS: A prospective observational study was conducted in a university hospital ICU. All consecutive patients admitted for septic shock or sepsis were included. Total cholesterol, HDL-C, low-density lipoprotein-cholesterol (LDL-C), and triglyceride levels were assessed at admission. Sepsis-associated liver dysfunction was defined as a serum bilirubin≥ 2N or aspartate aminotransferase/alanine aminotransferase concentrations ≥ 2N. Short-term and one-year prognostic outcomes were prospectively assessed. RESULTS: A total of 219 septic patients were included, and 15% of them presented with sepsis-associated liver dysfunction at admission. Low concentrations of lipoproteins were associated with mortality at Day 28 in the overall population. Sepsis-associated liver dysfunction at admission was associated with overmortality. In this subgroup, patients had a lower HDL-C concentration than patients without hepatic dysfunction (HDL-C = 0.31 [0.25, 0.55] mmol/L vs. 0.48 [0.29, 0.73] mmol/L, p = 0.0079) but there was no relationship with the outcome. Interestingly, no correlation was observed between lipoprotein concentrations and liver dysfunction markers. CONCLUSION: Sepsis-associated liver dysfunction at ICU admission is strongly associated with overmortality and is associated with a lower HDL-C concentration. However, in this subgroup of patients, HDL-C concentration had no relationship with mortality. Further exploratory studies are needed to better understand the interaction between lipoproteins and liver dysfunction during sepsis.

Renal Replacement Therapy for Patients Requiring Extracorporeal Membrane Oxygenation: A Multicenter International Survey.

INTRODUCTION: Patients receiving extracorporeal membrane oxygenation (ECMO) often require renal replacement therapy (RRT). The challenge of inserting a dialysis catheter (DC) could be solved by direct connection of RRT lines on an ECMO circuit (DCRE) without published guidelines. This study aimed to describe the practice of RRT in patients on ECMO, including the DCRE as well as the perception and concerns related to this technique. METHODS: An international survey was worldwide sent via email to professionals involved in the management of ECMO. Respondents always or often performing RRT via the ECMO circuit were classified in the ECMO group, and those using a DC were classified in the DC group. RESULTS: From March 2019 to October 2019, 298 participants answered the questionnaire from 46 different countries. Only 28% were working in pediatric departments. Among the 165 participants commonly performing RRT in patients on ECMO, 100 (61%) performed mainly RRT via the ECMO circuit, and 65 (39%) performed RRT via DC. Pediatric practice and a longer experience were the only noticeable characteristics of the ECMO group. The most reported concern regarding DCRE was the risk of air embolism (n = 84, 28%), but the most encountered problem was unmanageable pressure alarms in RRT devices. CONCLUSION: The present study showed significant heterogeneity in RRT practices in patients on ECMO. The lower experience of the DC group, the high rates of concerns toward DCRE, and pressure alarm issues suggested that protocols and training may overcome reluctance and technical difficulties.

The Prognostic Role of Early Postoperative Troponin I in Lung Transplantation-A Retrospective 7-Year Analysis.

OBJECTIVES: Postoperative cardiac troponin I concentration is predictive of worsened outcomes in cardiac surgery. Lung transplantation (LT) surgery shares common features with cardiac surgery, but postoperative troponin has yet to be investigated. The authors aimed to evaluate the association between early postoperative troponin concentration and the 1-year mortality after transplantation. DESIGN: A retrospective, observational, single-center study. SETTING: At a tertiary care, university hospital. PARTICIPANTS: Patients who underwent lung transplantation from January 2011 to December 2017 INTERVENTIONS: For each patient, preoperative, intraoperative, and postoperative data were collected, as well as the troponin I measurement at the moment of postoperative intensive care unit admission. MEASUREMENTS AND MAIN RESULTS: Two hundred twenty LT procedures were analyzed. Troponin I was elevated in all LT patients, with a median of 3.82 ng/mL-1 (2-6.42) ng/mL-1 significantly higher in non-survivors than in survivors with 5.39 (2.88-7.44) v 3.50 ng/mL (1.74-5.76), p = 0.005. In the multivariate analysis, the authors found that only the Simplified Acute Physiology Score II score (hazard ratio [HR] 1.03; 95% confidence interval [CI] [1.001; 1.05]; p = 0.007) and the need to maintain extracorporeal life support at the end of surgery (HR 2.54; 95% CI [1.36; 4.73]; p = 0.003) were independently associated with the 1-year mortality. The multiple linear regression model found that troponin levels were associated with the need for extracorporeal life support (ECLS) (p = 0.014), the amount of transfused packed red blood cells (p = 0.008), and bilateral LT (p < 0.001). CONCLUSION: Early postoperative troponin serum levels were not independently associated with 1-year mortality. Early postoperative troponin I levels were correlated to bilateral LT, the need for ECLS, and intraoperative blood transfusion.

Relationship between lipoprotein concentrations and short-term and 1-year mortality in intensive care unit septic patients: results from the HIGHSEPS study.

BACKGROUND: High-density lipoproteins (HDLs), particles characterized by their reverse cholesterol transport function, display pleiotropic properties, including anti-inflammatory and antioxidant functions. Moreover, all lipoproteins (HDLs but also low-density lipoproteins (LDLs)) neutralize lipopolysaccharides, leading to increased bacterial clearance. These two lipoproteins decrease during sepsis, and an association between low lipoprotein levels and poor outcome was reported. The goals of this study were to characterize the lipid profile of septic patients hospitalized in our intensive care unit (ICU) and to determine the relationship with the outcome. METHODS: A prospective observational study was conducted in a university hospital ICU. All consecutive patients admitted for septic shock or sepsis were included. Total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglyceride levels were assessed at admission (day 1), at day 3, and at ICU discharge. When available, a prehospitalization lipid profile collected prior to the patient's hospitalization was compiled. Short-term and 1-year prognostic outcomes were prospectively assessed. RESULTS: A total of 205 patients were included. We found a decrease in HDL-C concentration between previous values and those at admission, followed by an additional decrease at day 3. At ICU discharge, the concentration was higher than that at day 3 but did not reach the concentration measured prior to hospitalization (prior HDL-C = 1.22 (1.04-1.57) mmol/l; day 1 HDL-C = 0.44 (0.29-0.70) mmol/l; day 3 HDL-C = 0.30 (0.25-0.48) mmol/l; and HDL-C at discharge = 0.65 (0.42-0.82) mmol/l). A similar trend was found for LDL-C (prior LDL-C = 2.7 (1.91-3.33) mmol/l; day 1 LDL-C = 1.0 (0.58-1.50) mmol/l; day 3 LDL-C = 1.04 (0.64-1.54) mmol/l; and LDL-C at discharge = 1.69 (1.26-2.21) mmol/l). Mixed models for repeated measures of lipoprotein concentrations showed a significant difference in HDL-C and LDL-C concentrations over time between survivors and nonsurvivors at day 28. An HDL-C concentration at admission of less than 0.4 mmol/l was associated with increased mortality at day 28 (log-rank test, p = 0.034) but not at 1 year (log-rank test, p = 0.24). An LDL-C concentration at admission of less than 0.72 mmol/l was associated with increased mortality at day 28 and at 1 year (log-rank test, p < 0.001 and p = 0.007, respectively). No link was found between prior lipid profile and mortality. CONCLUSIONS: We showed no relationship between the prehospitalization lipid profile and patient outcome, but low lipoprotein levels in the ICU were strongly associated with short-term mortality.

Performance of pre-hospital evaluations in ruling out invasive chest stab wounds.

BACKGROUND: Some guidelines advocate for managing patients with penetrating thoracic wounds in trauma centres with cardiothoracic surgery. This systematic approach is questionable. Only 15% of these patients require surgery. It is known that clinical examination fails to detect hemopneumothorax in penetrating trauma. However, no studies have evaluated the combined diagnostic performance of vital signs and the clinical evaluation of wounds. The clinical characteristics of wounds have not been investigated. We aimed to evaluate the ability of combinations of pre-hospital signs to rule out invasive chest stab trauma. METHODS: This was a prospective observational study. All consecutive adult patients hospitalized in the perioperative acute care unit of a tertiary university hospital were included. Injury diagnoses were provided by exploratory surgery and imaging tests. Patients with a final diagnosis of invasive wounds (IWs) and patients with only superficial wounds were compared. Data regarding management and outcome were analysed. RESULTS: A total of 153 patients were included. After imaging or surgery, 58 (38%) patients were diagnosed with only superficial wounds, and 95 (62%) were diagnosed with thoracic or abdominal IWs. The false-negative rate of pre-hospital evaluations in the diagnosis of IWs was 42% [31-51]IQR25-75. In stable patients, pre-hospital data could not rule out IWs, with a negative predictive value of 58% and a positive predictive value of 70%. Twenty-nine (19%) patients required early emergent cardiothoracic surgery. Among these patients, 8 (28%) had no evidence of IWs in the pre-hospital period. Among the 59 patients without pre-hospital signs of IWs, 19 (33%) underwent at least one emergent procedure. CONCLUSIONS: The combination of pre-hospital vital signs, visual evaluation of wounds, and physical examination failed to rule out IWs in patients with chest stab wounds. This implies that caution is needed in triage decision-making.

Usefulness of Gram stain examination of peritoneal fluid in postoperative peritonitis to guide empirical antibiotherapy.

PURPOSE: In postoperative peritonitis, Gram stain examination (GSE) of peritoneal fluid has been proposed as a guide for the prescription of glycopeptides and antifungal therapy in empirical antibiotherapy. No data support this approach for Gram-positive cocci. We aimed to evaluate the performance of GSE in predicting the results of the culture of peritoneal fluid. METHODS: In this retrospective single-center study, concordance between GSE and culture of peritoneal fluid was assessed for different types of microorganisms. Factors associated with concordance of the two tests were evaluated in the subpopulation of Gram-positive cocci peritonitis. RESULTS: Among the 152 episodes, the GSE was negative in 57 cases. The negative predictive value and the positive predictive value were 41% and 87% for Gram-positive cocci (GPC), 31% and 86% for Gram-negative bacilli, and 78% and 94% for fungi. GSE is not a reliable guide for the choice of empirical antibiotherapy and cannot reliably rule out the presence of GPC at culture. If we aim to achieve a high rate of adequacy, the systematic use of glycopeptide in the empirical antibiotherapy may be considered. CONCLUSION: GSE shows poor performance to predict the results of culture of peritoneal fluid in postoperative peritonitis. Avoiding covering resistant GPC cannot be based on the result of GSE.

Usefulness of CT-scan in the management of chest stab trauma: a prospective observational study.

PURPOSE: The management of chest stab wounds necessitates to perform an efficient imaging strategy. Compared to chest X-ray, computed tomography (CT) scan has a higher sensitivity. Nevertheless, the utility of diagnosing occult injuries remains controversial. Previous studies reported very different rates of management modifications induced by CT-scan. Indeed, no study specifically addressed the issue of ruling out traumatic diaphragmatic injury (TDI) in the specific population of chest stab trauma. The aim of the study was to evaluate the rate of thoracic procedures induced or guided by the results of thoracic CT-scan in the specific population of chest stab wounds. Secondary objective was to evaluate the utility of CT-scan for the diagnosis of TDI. METHODS: We conducted a prospective observational study. All consecutive patients referred to the acute care unit were included. We recorded the general characteristics of patients, the localization of wounds, all imaging tests, the final injury diagnosis, and the patients' management. We compared patients with modifications of management induced by CT-scan results to other patients. We evaluated the performance of CT-scan for the diagnosis of TDI by calculating its sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). RESULTS: 153 patients were included. There were 92 patients with normal chest X-ray. 67 of them received a CT-scan. 34 (51%) patients had an abnormal CT-scan, including 19 (21%) patients with thoracic new findings, with 3 (4.5%) modification of management. There were 50 patients who had an abnormal chest X-ray. 31 of them received a CT-scan, and 31 (100%) had an abnormal CT-scan, including 19 thoracic new findings, with 11 (36%) modifications of management. The diagnostic performance of CT-scan for TDI was: sensitivity 50%; specificity 95%; NPV 72%; PPV 88%. CONCLUSIONS: In chest stab trauma, CT-scans may be unnecessary outside the thoracoabdominal zone when chest X-ray is normal. In other cases, CT-scan seems to have an impact on the decision-making. In case of thoracoabdominal wounds, CT-scan helps to detect intra-abdominal injuries. The performance of CT-scan to diagnose TDI is not high enough to reliably rule out all TDI.

Outcome and Adequacy of Empirical Antibiotherapy in Post-Operative Peritonitis: A Retrospective Study.

Background: Empirical antibiotherapy (EA) should target all bacteria in post-operative peritonitis (PP). Nevertheless, recent studies failed to prove a link between adequacy of EA and prognosis of PP. We sought to confirm this loss of association between adequate EA and prognosis and to analyze the evolution of patients' characteristics and antimicrobial strategies. Methods: This is was retrospective study. Patients with a positive fungal culture were excluded. The cohort was divided into two time periods. Data of survivors and non-survivors were compared within each time period. Differences between the two periods were assessed. A multivariable analysis searched for parameters associated with a higher hospital mortality rate. Results: Two hundred fifty-one patients were included, with 92 patients in the first period (P1) and 152 patients in the second period (P2). Inadequate EA was associated with a worse outcome only in P1. The multivariable analysis in the whole cohort showed that inadequate EA was associated with a higher mortality rate. When the differences noticed between the two periods were entered in the model (presence of resistant gram-positive cocci and EA comprising glycopeptides), inadequate EA was no longer associated with worse outcome. In P1, the most severe patients had more resistant bacteria, hence, had a higher rate of inadequate EA. This artifact disappeared in P2, during which broader antibiotherapies with triple EA were more often prescribed for the most severe patients. Conclusion: This study showed that the link between inadequate EA and outcome of patients with PP was at least partly artifactual in older studies.

Broken needle during spinal anesthesia: an avoidable complication.

The occurrence of a needle breaking is a very rare complication of spinal anesthesia (SA). We report a case of a broken spinal needle occurring in a morbid obese pregnant woman during SA indicated for an emergent cesarean section. Multiple puncture attempts due to difficult identification of lumbar spine, associated with an inadequate use of the introducer, contributed to this complication. The recognition of predictive factors for difficult neuraxial anesthesia, the use of ultrasound in obese patients, and a properly executed technique may have allowed avoiding this complication.

Impact of connecting continuous renal replacement therapy to the extracorporeal membrane oxygenation circuit.

PURPOSE: Continuous veno-venous haemofiltration (CVVH) directly connected to extracorporeal membrane oxygenation (ECMO) may ensure better blood flow and allow prolonged circuit life. The objective of this study was to assess circuit life of CVVH connected to ECMO and to a dialysis catheter. MATERIALS AND METHODS: In this prospective observational study, patients receiving CVVH via ECMO were compared to time-matched patients receiving CVVH via a conventional dialysis catheter. CVVH circuit life and the safety and efficacy of the two CVVH procedures were analysed. Time to event was estimated using Kaplan-Meier analysis and compared using the log-rank test. RESULTS: Seventeen patients were included in each group, with 43 sessions in the ECMO group and 56 sessions in the DC group. Median CVVH circuit life was 48 [21-72] vs 20 [6-39] hours in the ECMO and DC groups, respectively (relative risk of termination of the session: 2.4, 95% CI [1.41-3.9], log rank P=0.0009). CVVH blood flow was higher in the ECMO group. Despite higher anticoagulant doses in the catheter group, the circuit clotting rate was lower in the ECMO group. Effluent volume was slightly higher in the ECMO group (39ml/kg/h [33-47] vs 34ml/kg/h [32-39]), but with no biological impact. CVVH via ECMO was well tolerated with no major drawbacks. CONCLUSIONS: In patients requiring ECMO, CVVH connected to ECMO instead of DC could be proposed as an alternative approach, allowing more stable blood flow and prolonged CVVH circuit life.

Morbidity and mortality related to pneumonia and TRACHEOBRONCHITIS in ICU after lung transplantation.

BACKGROUND: Bacterial respiratory infections (BRI) are major complications contributing to increased morbidity and mortality after lung transplantation (LT). This study analyzed epidemiology and outcome of 175 consecutive patients developing BRI in ICU after LT between 2006 and 2012. METHODS: Three situations were described: colonization determined in donors and recipients, pneumonia and tracheobronchitis during the first 28 postoperative days. Severity score, demographic, bacteriologic and outcome data were collected. RESULTS: 26% of donors and 31% of recipients were colonized. 92% of recipients developed BRI, including at least one episode of pneumonia in 19% of recipients. Only 21% of recipients developed BRI with an organism cultured from the donor's samples, while 40% of recipients developed BRI with their own bacteria cultured before LT. Purulent sputum appears to be an important factor to discriminate tracheobronchitis from pneumonia. When compared to patients with tracheobronchitis, those with pneumonia had longer durations of mechanical ventilation (13 [3-27] vs 3 [29], p = 0.0005) and ICU stay (24 [16-34] vs 14 [9-22], p = 0.002). Pneumonia was associated with higher 28-day (11 (32%) vs 9 (7%), p = 0.0004) and one-year mortality rates (21 (61%) vs 24 (19%), p ≤ 0.0001). CONCLUSIONS: These data confirm the high frequency of BRI right from the early postoperative period and the poor prognosis of pneumonia after LT.

Evaluation of Cardiac Index and Extravascular Lung Water After Single-Lung Transplantation Using the Transpulmonary Thermodilution Technique by the PiCCO2 Device.

OBJECTIVES: First evaluation of the transpulmonary thermodilution technique by the PiCCO2 device to assess cardiac index and pulmonary edema during the postoperative course after single-lung transplantation. DESIGN: Prospective observational study. SETTINGS: Intensive care unit, university hospital (single center). PARTICIPANTS: Single-lung transplant patients. INTERVENTIONS: The authors compared cardiac index measured by PiCCO2 and pulmonary artery catheter and assessed pulmonary edema using extravascular lung water index and pulmonary vascular permeability index measured by PiCCO2. MEASUREMENTS AND MAIN RESULTS: A Bland-Altman method was used to compare cardiac index measured by PiCCO2 and pulmonary artery catheter. Extravascular lung water index and pulmonary vascular permeability index were compared according to the PaO2/FiO2 ratio with a threshold value of 150 mmHg. Ten single-lung transplant patients were included. Cardiac index measured by PiCCO2 and pulmonary artery catheter were 3.3 L/min/m2 (2.9-3.6) and 2.5 L/min/m2 (2.2-3.0). Bias for cardiac index was 0.71 L/min/m2 (-0.03; 1.44) and limit of agreements were -0.03 and 1.44 L/min/m2. Extravascular lung water index was 12 mL/kg (11-16) and pulmonary vascular permeability index was 2.3 (2.0-3.1), consistent with pulmonary edema. Extravascular lung water index was higher in the group of PaO2/FiO2 ratio ≤150 mmHg compared with the group of PaO2/FiO2 ratio >150 mmHg (17 v 12 mL/kg, p = 0.04), whereas pulmonary vascular permeability index only tended to be higher (3.1 v 2.1, p = 0.06). CONCLUSION: PiCCO2 device systematically overestimated cardiac index compared with pulmonary artery catheter. However, it might be useful to assess pulmonary edema in acute respiratory failure after single-lung transplantation.

Head Computed Tomography Scan in Isolated Traumatic Brain Injury in a Low-Income Country.

BACKGROUND: Head computed tomography scan (HCTS) is the cornerstone of the management of traumatic brain injury (TBI). The impact of performing a HCTS in TBI has been scarcely investigated in low-income countries (LICs). Furthermore, the cost of a HCTS is a burden for family finances. METHODS: A prospective observational study was conducted in Burkina Faso. All consecutive patients with isolated TBI needing a HCTS were included. Result and impact of HCTS were evaluated. RESULTS: There were 183 patients prescribed a HCTS for an isolated TBI. Mild, moderate, and severe TBIs represented 55%, 31%, and 14% of the cases, respectively. In 72 patients, HCTS was not performed because of economic barrier. Among the 110 HCTSs performed, there were intracranial lesions in 81 (74%) patients. Among the 110 performed HCTS, 34 (31% [22.3%-39.5%]) HCTSs altered the management of TBI, with 16 (15%) cases of surgical indications, and 20 (18%) cases of modification of the medical treatment. In patients without neurologic signs, the rate of alteration of management was 28%. The realization of the HCTSs was associated with the presence of neurologic signs and income level. In-hospital mortality was 11% (n = 21). Among the 162 patients discharged alive from the hospital, 27 (20%) were discharged with a severe disability state (Glasgow Outcome Scale score ≤3). The rate of return to work was 77%. CONCLUSIONS: No modification of guidelines can be advocated from this study. However, given the financial burden on family of performing HCTS, research may identify criteria allowing for avoiding HCTS. Guidelines specific to LICs are needed to get closer to the best interest of patients.

A Comparison of a Machine Learning Model with EuroSCORE II in Predicting Mortality after Elective Cardiac Surgery: A Decision Curve Analysis.

BACKGROUND: The benefits of cardiac surgery are sometimes difficult to predict and the decision to operate on a given individual is complex. Machine Learning and Decision Curve Analysis (DCA) are recent methods developed to create and evaluate prediction models. METHODS AND FINDING: We conducted a retrospective cohort study using a prospective collected database from December 2005 to December 2012, from a cardiac surgical center at University Hospital. The different models of prediction of mortality in-hospital after elective cardiac surgery, including EuroSCORE II, a logistic regression model and a machine learning model, were compared by ROC and DCA. Of the 6,520 patients having elective cardiac surgery with cardiopulmonary bypass, 6.3% died. Mean age was 63.4 years old (standard deviation 14.4), and mean EuroSCORE II was 3.7 (4.8) %. The area under ROC curve (IC95%) for the machine learning model (0.795 (0.755-0.834)) was significantly higher than EuroSCORE II or the logistic regression model (respectively, 0.737 (0.691-0.783) and 0.742 (0.698-0.785), p < 0.0001). Decision Curve Analysis showed that the machine learning model, in this monocentric study, has a greater benefit whatever the probability threshold. CONCLUSIONS: According to ROC and DCA, machine learning model is more accurate in predicting mortality after elective cardiac surgery than EuroSCORE II. These results confirm the use of machine learning methods in the field of medical prediction.

CRRT Connected to ECMO: Managing High Pressures.

Metabolic disorders and fluid overload are indications of continuous renal replacement therapy (CRRT) including continuous venovenous hemofiltration in patients on extracorporeal membrane oxygenation (ECMO). Direct connection of CRRT machine to the ECMO circuit provides many advantages. Nevertheless, because pressures in CRRT lines relate to ECMO blood flow, high ECMO blood flow may be associated with high pressures in CRRT lines. Thus, management of CRRT pressure lines becomes challenging. We evaluated a protocol for managing high CRRT pressures. Connections were performed according to a standardized protocol to maintain CRRT lines in the correct pressure ranges without modifying ECMO settings or inhibiting pressure alarms. To achieve this goal, the way of connecting of CRRT lines was adapted following a standardized protocol. Connection was first attempted between pump and oxygenator in the 12 patients. In five cases, high pressures in CRRT lines were successfully managed by changing the connection segment. Continuous renal replacement therapy parameters were within target levels and reduction of serum creatinine was 37%. In conclusion, management of high pressures in CRRT lines induced by ECMO could be achieved without modifying ECMO blood flow or inhibiting CRRT alarms. Iterative stops were avoided allowing efficient procedures.