Implementation of a regional multidisciplinary veno-venous extracorporeal membrane oxygenation unit improved survival: a historical cohort study.

PURPOSE: Veno-venous extracorporeal membrane oxygenation (vvECMO) is a highly invasive technique with a high risk of mortality. Based on reports of improved outcomes in high-volume ECMO centers, we established a regional vvECMO unit. The objective of this study was to evaluate how the vvECMO unit affected patient mortality rates. METHODS: This was a historical cohort study of all patients admitted to Dijon University Hospital and supported by vvECMO between January 2011 and June 2021. Patients managed with the vvECMO unit were compared with patients managed with non-vvECMO units. The primary outcome was 90-day mortality. RESULTS: Of 172 patients treated using vvECMO, 69% were men, and the median [interquartile range] age was 59 [48-66] yr. Of the 172 patients, 35 were treated in the vvECMO unit and 137 were treated elsewhere (110/137 before the unit was established and 27/137 after). Ninety-day mortality was lower in patients managed in the vvECMO unit (15/35, 43% vs 92/137, 67%; P = 0.005). Within the vvECMO unit, mortality rates were also lower for the subgroup of patients managed after the specialized unit was established (15/35, 43% vs 20/27, 74%; P = 0.002). After adjusting for baseline severity of illness at vvECMO initiation, the vvECMO unit was independently associated with a lower 90-day mortality rate (hazard ratio, 0.41; 95% confidence interval, 0.21 to 0.80). CONCLUSION: The establishment of a vvECMO unit was associated with reduced 90-day mortality. This improved survival may relate to patient selection, more specialized mechanical ventilation support, and/or improvement of vvECMO care.

RéSUMé: OBJECTIF: L'oxygénation par membrane extracorporelle veino-veineuse (ECMO-VV) est une technique hautement invasive qui s'accompagne d'un risque élevé de mortalité. Sur la base de comptes rendus faisant état d'améliorations des devenirs dans les centers pratiquant un volume important d'ECMO, nous avons mis en place une unité régionale d'ECMO-VV. L'objectif de cette étude était d'évaluer l'impact de l'unité d'ECMO-VV sur les taux de mortalité des patients. MéTHODE: Nous avons réalisé une étude de cohorte historique incluant tous les patients admis au CHU de Dijon et traités par ECMO-VV entre janvier 2011 et juin 2021. Les patients pris en charge par l'unité d'ECMO-VV ont été comparés aux patients pris en charge par d'autres unités. Le critère d'évaluation principal était la mortalité à 90 jours. RéSULTATS: Sur 172 patients traités par ECMO-VV, 69 % étaient des hommes et l'âge médian [écart interquartile] était de 59 [48-66] ans. Sur les 172 patients, 35 ont été traités par l'unité d'ECMO-VV et 137 ont été traités ailleurs (110/137 avant la création de l'unité et 27/137 après). La mortalité à 90 jours était plus faible chez les patients pris en charge par l'unité d'ECMO-VV (15/35, 43 % vs 92/137, 67 %; P = 0,005). Au sein de l'unité d'ECMO-VV, les taux de mortalité étaient également plus faibles pour le sous-groupe de patients pris en charge après la création de l'unité spécialisée (15/35, 43 % vs 20/27, 74 %; P = 0,002). Après ajustement pour tenir compte de la gravité initiale de la maladie à la mise en place de l'ECMO-VV, l'unité d'ECMO-VV était indépendamment associée à un taux de mortalité plus faible à 90 jours (rapport de risque, 0,41; intervalle de confiance à 95 %, 0,21 à 0,80). CONCLUSION: La mise en place d'une unité d'ECMO-VV a été associée à une réduction de la mortalité à 90 jours. Cette amélioration de la survie peut être liée à la sélection des patients, à un soutien par ventilation mécanique plus spécialisé et /ou à l'amélioration des soins d'ECMO-VV.

Fasting does not guarantee empty stomach in the intensive care unit: A prospective ultrasonographic evaluation (The NUTRIGUS study).

BACKGROUND: In the intensive care unit (ICU), a fasting period is usually respected to avoid gastric aspiration during airway management procedures. Since there are no recognised guidelines, intensive care physicians balance the aspiration risk with the negative consequences of underfeeding. Our objective was to determine the impact of fasting on gastric emptying in critically ill patients by using gastric ultrasound. MATERIAL AND METHODS: Among the 112 patients that met the inclusion criteria, 100 patients were analysed. Gastric ultrasonography was performed immediately before extubation. Patients with either 1/ an absence of visualised gastric content (qualitative evaluation) or 2/ a gastric volume < 1.5 mll/kg in case of clear fluid gastric content (quantitative evaluation) were classified as having an empty stomach. MAIN FINDINGS: In our study, twenty-six (26%) patients had a full stomach at the time of extubation. The incidence of full stomach was not significantly different between patients who fasted < 6 h or patients who fasted ≥ 6 h. Among the 57 patients receiving enteral nutrition (EN) within the last 48 h, there was no correlation between the duration of EN interruption and the GAA. The absence of EN was not associated with an empty stomach. CONCLUSION: At the time of extubation, the incidence of full stomach was high and not associated with the fasting characteristics (duration/absence of EN). Our results support the notions that fasting before airway management procedures is not a universal paradigm and that gastric ultrasound might represent a useful tool in the tailoring process. CLINICALTRIALS.GOV: NCT04245878.

Pupillometry pain index decreases intraoperative sufentanyl administration in cardiac surgery: a prospective randomized study.

Pupillometry has proven effective for the monitoring of intraoperative analgesia in non-cardiac surgery. We performed a prospective randomized study to evaluate the impact of an analgesia-guided pupillometry algorithm on the consumption of sufentanyl during cardiac surgery. Fifty patients were included prior to surgery. General anesthesia was standardized with propofol and target-controlled infusions of sufentanyl. The standard group consisted of sufentanyl target infusion left to the discretion of the anesthesiologist. The intervention group consisted of sufentanyl target infusion based on the pupillary pain index. The primary outcome was the total intraoperative sufentanyl dose. The total dose of sufentanyl was lower in the intervention group than in the control group and (55.8 µg [39.7-95.2] vs 83.9 µg [64.1-107.0], p = 0.04). During the postoperative course, the cumulative doses of morphine (mg) were not significantly different between groups (23 mg [15-53] vs 24 mg [17-46]; p = 0.95). We found no significant differences in chronic pain at 3 months between the 2 groups (0 (0%) vs 2 (9.5%) p = 0.49). Overall, the algorithm based on the pupillometry pain index decreased the dose of sufentanyl infused during cardiac surgery.Clinical trial number: NCT03864016.

Anemia before reimplantation surgery - An overlooked modifiable risk factor of septic revision knee arthroplasty failure.

INTRODUCTION: Preoperative anemia in patients undergoing a two-stage septic revision arthroplasty may be a factor of reinfection, even in the presence of aggressive antimicrobial therapy. Patient Blood Management (PBM) in such patients is challenging. We evaluate the impact of anemia existing before re-implantation on a failure rate after two-stage septic total knee arthroplasty (rTKA), and explore feasibility of a PBM strategy implementation in these patients. MATERIALS AND METHODS: A retrospective study of patients from January 2010 to January 2015 in a French regional referral center was performed. Patients undergoing a two-stage rTKA for infection after successful primary TKA were identified and followed up to 31.12.2018. The primary outcome (failure) was defined as surgical site infection after re-implantation requiring new surgery. The secondary outcomes were time to failure, the time between explantation/reimplantation, transfusion rate during the second stage. Preoperative anemia was defined as Hb level < 12 g/L before the re-implantation. RESULTS: 69 patients were identified; 17 (24%) developed reinfection of rTKA in 105 [11.4-156] days. In these patients pre-implantation anemia was more frequent (n = 13(76.5%) in failed vs. n = 21(40%) in non-failed, p = 0.0110). During the explantation stage, there were no significant group differences in age, sex, comorbidity, type of spacer and antimicrobial therapy, iron supplementation, or transfusion rate. The median time between explantation/reimplantation surgery was 51 [43-71.5] days, indifferent between the two groups. Intraoperative transfusion during reimplantation was required in 12 (17%) patients, more frequent in failed patients. None of the patients had contraindications for the PBM strategy except the cell-saver use. CONCLUSION: In two-stage septic rTKA preoperative anemia was almost two times more frequent and associated with an elevated rate of septic failure. The time-frame between explantation and-re-implantation is sufficient to implement a PBM strategy for all anemic patients. Before-after studies would be of interest to determine the best PBM strategy to prevent anemia-associated septic failure in such a condition.