Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography: A Comparative Study.

BACKGROUND: To assess the agreement between transpulmonary thermodilution (TPT) and critical care echocardiography (CCE) in ventilated patients with septic shock. METHODS: Ventilated patients in sinus rhythm requiring advanced hemodynamic assessment for septic shock were included in this prospective multicenter descriptive study. Patients were assessed successively using TPT and CCE in random order. Data were interpreted independently at bedside by two investigators who proposed therapeutic changes on the basis of predefined algorithms. TPT and CCE hemodynamic assessments were reviewed offline by two independent experts who identified potential sources of discrepant results by consensus. Lactate clearance and outcome were studied. RESULTS: A total of 137 patients were studied (71 men; age, 61 ± 15 years; Simplified Acute Physiologic Score, 58 ± 18; Sequential Organ Failure Assessment, 10 ± 3). TPT and CCE interpretations at bedside were concordant in 87/132 patients (66%) without acute cor pulmonale (ACP), resulting in a moderate agreement (kappa, 0.48; 95% CI, 0.37-0.60). Experts' adjudications were concordant in 100/129 patients without ACP (77.5%), resulting in a good intertechnique agreement (kappa, 0.66; 95% CI, 0.55-0.77). In addition to ACP (n = 8), CCE depicted a potential source of TPT inaccuracy in 8/29 patients (28%). Lactate clearance at H6 was similar irrespective of the concordance of online interpretations of TPT and CCE (55/84 [65%] vs 32/45 [71%], P = .55). ICU and day 28 mortality rates were similar between patients with concordant and discordant interpretations (29/87 [36%] vs 13/45 [29%], P = .60; and 31/87 [36%] vs 16/45 [36%], P = .99, respectively). CONCLUSIONS: Agreement between TPT and CCE was moderate when interpreted at bedside and good when adjudicated offline by experts, but without impact on lactate clearance and mortality.

Optimization of Positive End-Expiratory Pressure Targeting the Best Arterial Oxygen Transport in the Acute Respiratory Distress Syndrome: The OPTIPEP Study.

The optimal setting for positive end-expiratory pressure (PEEP) in mechanical ventilation remains controversial in the treatment of acute respiratory distress syndrome (ARDS). The aim of this study was to determine the optimum PEEP level in ARDS, which we defined as the level that allowed the best arterial oxygen delivery (DO2). We conducted a physiologic multicenter prospective study on patients who suffering from ARDS according to standard definition and persistent after 6 hours of ventilation. The PEEP was set to 6 cm H2O at the beginning of the test and then was increased by 2 cm H2O after at least 15 minutes of being stabilized until the plateau pressure achieved 30 cm H2O. At each step, the cardiac output was measured by transesophageal echocardiography and gas blood was sampled. We were able to determine the optimal PEEP for 12 patients. The ratio of PaO2/FiO2 at inclusion was 131 ± 40 with a mean FiO2 of 71 ± 3%. The optimal PEEP level was lower than the higher PEEP despite a constant increase in SaO2. The optimal PEEP levels varied between 8 and 18 cm H2O. Our results show that in patients with ARDS the optimal PEEP differs between each patient and require being determined with monitoring.

The effects of beta-blockers in patients with stable chronic heart failure. Predictors of left ventricular ejection fraction improvement and impact on prognosis.

BACKGROUND: Previous studies, with limited number of patients, have tried to determine the predictors of left ventricular ejection fraction (LVEF) improvement after beta-blockade. No study has demonstrated that LVEF improvement was an independent predictor of cardiac survival. METHODS: The aims of the study were to determine in a large group of patients with stable chronic heart failure associated with reduced LVEF the predictors of LVEF improvement (difference in LVEF [deltaLVEF], ie, the value after beta-blockade minus the value before beta-blockade) after beta-blockade and to analyze prognostic impact of deltaLVEF. Three hundred fourteen consecutive patients underwent an echocardiogram, a radionuclide angiogram, and a maximum cardiopulmonary exercise test before and 3 months after maximal tolerated doses of beta-blockers have been reached. RESULTS: After beta-blockade, LVEF improved from 30% +/- 11% to 40% +/- 13%. In the whole population, independent predictors of deltaLVEF were nonischemic etiology, baseline LVEF (negative correlation), and baseline heart rate (positive correlation). In ischemic patients, independent predictors of deltaLVEF were absence of history of myocardial infarction, baseline heart rate, and baseline LVEF; whereas in nonischemic patients, independent predictors were baseline LVEF and baseline QRS width (negative correlation). After 1082 days of follow-up, there were 53 cardiovascular deaths and 2 urgent transplantations. Left ventricular ejection fraction improvement (defined as an absolute increase in LVEF > 5%) was an independent predictor of cardiac survival. Patients who had an LVEF < or = 45% after beta-blockade with a deltaLVEF < or = 5% represented a high-risk subgroup. CONCLUSIONS: In patients with chronic heart failure, predictors of LVEF improvement after beta-blockade were different according to etiology. Left ventricular ejection fraction improvement was an independent predictor of cardiac survival.

Can dynamic indicators help the prediction of fluid responsiveness in spontaneously breathing critically ill patients?

OBJECTIVE: To investigate whether the respiratory changes in arterial pulse (DeltaPP) and in systolic pressure (DeltaSP) could predict fluid responsiveness in spontaneously breathing (SB) patients. Because changes in intrathoracic pressure during spontaneous breathing (SB) might be insufficient to modify loading conditions of the ventricles, performances of indicators were also assessed during a forced respiratory maneuver. DESIGN: Prospective interventional study. SETTING: A 34-bed university hospital medico-surgical ICU. PATIENTS AND PARTICIPANTS: Thirty-two SB patients with clinical signs of hemodynamic instability. INTERVENTION: A 500-ml volume expansion (VE). MEASUREMENTS AND RESULTS: Cardiac index, assessed using transthoracic echocardiography, increased by at least 15% after VE in 19 patients (responders). At baseline, only dynamic indicators were higher in responders than in nonresponders (13+/-5% vs. 7+/-3%, p=0.003 for DeltaPP and 10+/-4% vs. 6+/-2%, p=0.002 for DeltaSP). Moreover, they significantly decreased after VE (11+/-5% to 6+/-4%, p<0.001 for DeltaPP and 8+/-4% to 6+/-3%, p<0.001 for DeltaSP). DeltaPP and DeltaSP areas under the ROC curve were high (0.81+/-0.08 and 0.82+/-0.08; p=0.888, respectively). A DeltaPP>or=12% predicted fluid responsiveness with high specificity (92%) but poor sensitivity (63%). The forced respiratory maneuver reproducing a dyspneic state decreased the predictive power. CONCLUSIONS: Due to their lack of sensitivity and their dependence to respiratory status, DeltaPP and DeltaSP are clearly less reliable to predict fluid responsiveness during SB than in mechanically ventilated patients. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely.

Effect of ventilator-associated tracheobronchitis on outcome in patients without chronic respiratory failure: a case-control study.

INTRODUCTION: Our objective was to determine the effect of ventilator-associated tracheobronchitis (VAT) on outcome in patients without chronic respiratory failure. METHODS: This was a retrospective observational matched study, conducted in a 30-bed intensive care unit (ICU). All immunocompetent, nontrauma, ventilated patients without chronic respiratory failure admitted over a 6.5-year period were included. Data were collected prospectively. Patients with nosocomial pneumonia, either before or after VAT, were excluded. Only first episodes of VAT occurring more than 48 hours after initiation of mechanical ventilation were studied. Six criteria were used to match cases with controls, including duration of mechanical ventilation before VAT. Cases were compared with controls using McNemar's test and Wilcoxon signed-rank test for qualitative and quantitative variables, respectively. Variables associated with a duration of mechanical ventilation longer than median were identified using univariate and multivariate analyses. RESULTS: Using the six criteria, it was possible to match 55 (87%) of the VAT patients (cases) with non-VAT patients (controls). Pseudomonas aeruginosa was the most frequently isolated bacteria (34%). Although mortality rates were similar between cases and controls (29% versus 36%; P = 0.29), the median duration of mechanical ventilation (17 days [range 3-95 days] versus 8 [3-61 days]; P < 0.001) and ICU stay (24 days [range 5-95 days] versus 12 [4-74] days; P < 0.001) were longer in cases than in controls. Renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.6-14.6; P = 0.004), tracheostomy (OR = 4, 95% CI = 1.1-14.5; P = 0.032), and VAT (OR = 3.5, 95% CI = 1.5-8.3; P = 0.004) were independently associated with duration of mechanical ventilation longer than median. CONCLUSION: VAT is associated with longer durations of mechanical ventilation and ICU stay in patients not suffering from chronic respiratory failure.

First-generation fluoroquinolone use and subsequent emergence of multiple drug-resistant bacteria in the intensive care unit.

OBJECTIVE: The objective of this study was to determine the relationship between fluoroquinolone (FQ) use and subsequent emergence of multiple drug-resistant bacteria (MRB) in the intensive care unit (ICU). DESIGN: The authors conducted a prospective observational cohort study and a case control study. SETTING: The study was conducted in a 30-bed ICU. METHODS: All immunocompetent patients hospitalized for >48 hrs who did not receive antibiotics before ICU admission were eligible during a 15-month period. Routine MRB screening was performed at ICU admission and weekly thereafter. This screening included tracheal aspirate and nasal, anal, and axilla swabs. Univariate and multivariate analyses were used to determine risk factors for MRB emergence in the ICU. In addition, a case control study was performed to determine whether FQ use is associated with subsequent emergence of MRB. RESULTS: Two hundred thirty-nine patients were included; 108 ICU-acquired MRB were isolated in 77 patients. FQ use and longer duration of antibiotic treatment were identified as independent risk factors for MRB occurrence (odds ratio [95% confidence interval [CI] = 3.3 [1.7-6.5], 1.1 [1.0-1.2]; p < .001; respectively). One hundred thirty-five (56%) patients received FQ; matching was successful for 72 (53%) of them. Number of MRB (40 vs. 15 per 1,000 ICU days; p = .019) and percentage of patients with MRB (40% vs. 22%; OR [95% CI] = 1.5 [1.0-2.4]; p = .028) were significantly higher in cases than in controls. Although methicillin-resistant Staphylococcus aureus (26% vs. 12%; OR [95% CI] = 1.6 [.6-2.9]; p = .028) and extending-spectrum beta-lactamase-producing Gram-negative bacilli (11% vs. 1%; OR [95% CI] = 4.7 [0.7-30.2]; p = .017) rates were higher in cases than in controls, ceftazidime or imipenem-resistant Pseudomonas aeruginosa (15% vs. 8%), Acinetobacter baumannii (1% vs. 5%), and Stenotrophomonas maltophilia (2% vs. 1%) rates were similar (p > .05) in case and control patients. CONCLUSION: FQ use and longer duration of antibiotic treatment are independently associated with MRB emergence. Reducing antimicrobial treatment duration and restricting FQ use could be suggested to control MRB spread in the ICU.