Comparison Between Continuous and Intermittent Administration of Hydrocortisone During Septic Shock: A Randomized Controlled Clinical Trial.

OBJECTIVES: The best modality of administration of hydrocortisone during septic shock has been poorly evaluated and the guidelines remain unclear in this respect. This study aimed to compare bolus of hydrocortisone to a continuous infusion during septic shock. DESIGN: Randomized controlled, open-label trial. SETTING: Medical ICU of a university hospital. PATIENTS: Adult patients with septic shock requiring more than 2 mg/h (approximately 33.3 µg/mn) of norepinephrine after adequate fluid administration were eligible.Patients already receiving corticosteroids or who have a contraindication to corticosteroids, patients who died within 24 h and those with a decision of not to resuscitate were excluded. INTERVENTIONS: Patients were randomized either to receive hydrocortisone 200 mg/d by continuous infusion or by boluses of 50 mg every 6 h throughout the prescription of vasopressors with a maximum of 7 days. RESULTS: Twenty-nine patients were included in each group. Shock reversal was significantly higher in the HC bolus group (66% vs. 35%, P = 0.008). The median time to shock reversal was 5 days (95% CI, 4.31-5.69) in the HC bolus group compared to 6 days (95% CI, 4.80-7.19) in the HC continuous infusion group (log Rank = 0.048). The number of hours spent with blood glucose ≥ 180 mg/dL was higher in the HC continuous infusion group with a median of 64 h [IQR (2-100)] versus 48 h [IQR (14-107)] in the HC bolus group, (P = 0.60), and daily insulin requirements were similar between the two groups (P = 0.63). The occurrence of other side effects, mortality, and ICU LOS were similar between the study groups. CONCLUSION: Hydrocortisone administered by intermittent bolus was associated with higher shock reversal at day 7 compared with a continuous infusion.

Which indicators used to assess quality performance in Intensive Care Units? A systematic review of medical literature.

OBJECTIVE: Collect, through a literature review, the indicators recommended for the measurement of performance in the Intensive Care Unit (ICU) and determine their typology. METHODS: This systematic review was conducted in Medline, using the following search strategy: ("Critical Care"[Mesh] or "Critical Care Nursing"[Mesh] or "Intensive Care Units"[Mesh]) and "Quality Indicators, Health Care"[Mesh] and (hasabstract[text] and "2012/01/01"[PDat]: "2016/12/31"[PDat] AND "humans"[MeSH Terms] and [English(lang) or French(lang)]). RESULTS: Overall, a total of 176 articles were selected for inclusion, of which 140 articles were available. The most frequent journal was: "Critical Care Medicine" (12%). Half of the articles have been published in USA. The analysis of these articles allowed the development of a list of 92 performance indicators in the ICU. The majority of quality indicators were global (63%) and used in a polyvalent ICU (86%). Regarding the domain, the indicators were distributed as follows: 19% "input", 40% "process" and 41% "output". CONCLUSION: This study proposes a set of close to one hundred most-studied ICU performance indicators related essentially to "process". This study is only the first step in a performance improvement quality. The next step will be to use these indicators to develop a performance dashboard of the ICU based on clinical expertise.

Outbreak of colistin-resistant carbapenemase-producing Klebsiella pneumoniae in Tunisia.

OBJECTIVES: Mechanisms of colistin and carbapenem resistance among a collection of Klebsiella pneumoniae isolates recovered in a university hospital in Tunisia were studied. METHODS: In vitro antimicrobial susceptibility testing, S1 nuclease pulsed-field gel electrophoresis (S1-PFGE), Southern blotting and PCR-based replicon typing (PBRT) were performed. Extended-spectrum ß-lactamases (ESBLs), carbapenemases, AmpC-type enzymes and mgrB genes were detected by PCR and sequencing. Clonality of isolates was assessed by PFGE and multilocus sequence typing (MLST). RESULTS: Of 940 Enterobacteriaceae isolates recovered from June 2015 to March 2016 in Tahar Sfar Hospital (Mahdia, Tunisia), 220 were identified as K. pneumoniae, among which 29 were carbapenem-resistant. Carbapenem resistance was mostly due to expression of blaOXA-48 or blaOXA-204 in combination with blaCMY-4. Seven isolates carried blaNDM-1, of which two also harboured blaOXA-48, together with blaCMY-16 in one of them. All but two isolates also harboured blaCTX-M-15. All 20 blaOXA-48 genes were part of transposon Tn1999 on an IncL plasmid, whereas blaOXA-204 was found on transposon Tn2016 on an IncA/C plasmid. Finally, all blaNDM-1 genes were located within a Tn125 transposon on an IncFIIk plasmid. Interestingly, 7 (24.1%) of 29 carbapenem-resistant isolates were resistant to colistin, of which 6 were assigned to ST101, had similar PFGE profiles and presented the same 2-kb insertion in the mgrB gene. CONCLUSIONS: This study reports, for the first time in Tunisia, the full molecular characterisation of colistin resistance in K. pneumoniae. There is an urgent need for control measures and prudent use of colistin in treatment of infections with carbapenemase-producing K. pneumoniae.

Scorpion-related cardiomyopathy: Clinical characteristics, pathophysiology, and treatment.

CONTEXT: Scorpion envenomation is a threat to more than 2 billion people worldwide with an annual sting number exceeding one million. Acute heart failure presenting as cardiogenic shock or pulmonary edema, or both is the most severe presentation of scorpion envenomation accounting for 0.27% lethality rate. OBJECTIVE: The purpose of this review is to characterize the scorpion-related cardiomyopathy, clarify its pathophysiological mechanisms, and describe potentially useful treatments in this particular context. METHODS: We searched major databases on observational or interventional studies (whether clinical or experimental) on the cardiorespiratory consequences of scorpion envenomation and their treatment. No limit of age or language was imposed. A critical appraisal of the literature was conducted in order to provide a pathophysiological scheme that reconciles reported patterns of cardiovascular toxicity and hypotheses and assumptions made so far. RESULTS: Early cardiovascular dysfunction is related to the so-called "vascular phase" of scorpion envenomation, which is related to a profound catecholamine-related vasoconstriction leading to a sharp increase in left ventricular (LV) afterload, thereby impeding LV emptying, and increasing LV filling pressure. Following this vascular phase, a myocardial phase occurs, characterized by a striking alteration in LV contractility (myocardial stunning), low cardiac output, and hypotensive state. The right ventricle involvement is symmetric to that of LV with a profound and reversible alteration in right ventricular performance. This phase is unique in that it is reversible spontaneously or under inotropic treatment. Scorpion myocardiopathy combines the features of takotsubo myocardiopathy (or stress myocardiopathy) which is linked to a massive release in catecholamines leading to myocardial ischemia through coronary vasomotor abnormalities (epicardial coronary spasm and/or increase in coronary microvascular resistance). Treatment of pulmonary edema due to scorpion envenomation follows the same principles as those applied for the treatment of cardiogenic pulmonary edema in general: this begins with oxygen supplementation targeting an oxygen saturation of 92% or more, by oxygen mask, continuous positive airway pressure, noninvasive ventilation, or conventional mechanical ventilation. Dobutamine effectively improves hemodynamic parameters and may reduce mortality in severe scorpion envenomation. CONCLUSION: Scorpion cardiomyopathy is characterized by a marked and reversible alteration in biventricular performance. Supportive treatment relying on ventilatory support and dobutamine infusion is a bridge toward recovery in the majority of patients.

N-terminal proB-type natriuretic peptide levels aid the diagnosis of left ventricular dysfunction in patients with severe acute exacerbations of chronic obstructive pulmonary disease and renal dysfunction.

BACKGROUND AND OBJECTIVE: The aim of this study was to assess the performance of N-terminal proB-type natriuretic peptide (NT-proBNP) levels for the diagnosis of left ventricular dysfunction in patients with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) and renal dysfunction. METHODS: NT-proBNP levels at admission were measured in consecutive patients admitted to two participating intensive care units with acute exacerbations of COPD. Left ventricular dysfunction was assessed on the basis of clinical and echocardiographic criteria. The performance of NT-proBNP levels was evaluated in patients with or without renal dysfunction. RESULTS: Among the 120 patients included in the study, 70 had impaired renal function, defined as a glomerular filtration rate of <90 mL/min/1.73 m(2). NT-proBNP levels were inversely correlated with glomerular filtration rate (Spearman's correlation coefficient = -0.457, P < 0.001). Overall, left ventricular dysfunction was diagnosed in 58 patients (48.3%). Median NT-proBNP levels were significantly higher in these patients, irrespective of whether their renal function was normal (3313 (interquartile range (IQR) 4603) vs 337 (IQR 695) pg/mL, P < 0.001) or impaired (5692 (IQR 10714) vs 887 (IQR 1165) pg/mL, P < 0.001). The areas under the receiver operating characteristic curves were 0.87 and 0.78, respectively. The threshold NT-proBNP value with the highest diagnostic accuracy was greater in the setting of renal dysfunction (2000 pg/mL; sensitivity 71%, specificity 82%, compared with 1000 pg/mL in patients with normal renal function; sensitivity 94%, specificity 82%). Multivariate analysis showed that left ventricular dysfunction and glomerular filtration rate were independently associated with elevated NT-proBNP levels. CONCLUSIONS: NT-proBNP remains an accurate biomarker for the diagnosis of left ventricular dysfunction associated with acute exacerbations of COPD. Threshold values of NT-proBNP were higher in patients with impaired renal function than in those with normal renal function.

Impact of anemia on outcome in critically ill patients with severe acute renal failure.

OBJECTIVE: To evaluate the prognostic value of hemoglobin levels in critically ill patients with acute renal failure (ARF) requiring dialysis. DESIGN AND SETTING: A prospective observational cohort study in two adult medical ICUs. PATIENTS: 206 consecutive patients with ARF who required dialysis. Overall 28-day mortality was 48%. MEASUREMENTS AND RESULTS: At ICU admission mean hemoglobin level was 9.1+/-2.1 g/dl. By ROC curve analysis the threshold value of hemoglobin with the highest sensibility/specificity was 9 g/dl. At baseline 63% of patients had anemia, defined as initial hemoglobin below 9 g/dl. Kaplan-Meier analysis showed that these patients had lower survival rate than those with hemoglobin above 9 g/dl. By multivariable analysis three factors were independently associated with 28-day death: hemoglobin lower than 9 g/dl (adjusted odds ratio 2.4, 95% CI 1.1-5.2), age, and SOFA score. Based on age and SOFA a matched cohort analysis of 67 pairs of ARF patients with or without anemia found similar results regarding the negative impact of anemia on outcome. Finally, a multivariable logistic regression analysis on matched cohort identified hemoglobin level below 9 g/dl (adjusted odds ratio 1.32, 95%CI 1.15-1.46), continuous renal replacement therapy, and vasoactive therapy as independent predictors of 28-day death. CONCLUSIONS: These results suggest that initial hemoglobin level could be helpful in identifying patients with ARF requiring dialysis at high risk of death.