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Secondary outcomes were ICU and hospital-mortality and adverse events complications related to device use. Results: We present preliminary results from 47 patients recruited in 6 centers 29 men, 18 women, mean age The utilization rate was of 0. Thirty-nine patients were under invasive and 8 under noninvasive mechanical ventilation. Eighteen patients were treated as a part of a clinical trial and 29 were treated as decided by the physician in charge according to current practice. Twenty-five ECCO2R treatments were discontinued because of clinical condition improvement, 10 because of complications, 7 because of death and 5 for futility.
Safety remains a major concern, indicating the need for further technological improvements as well of for optimization of anticoagulation regimen. Therefore, the effect of a SRP on the development of ventilator-associated pneumonia is uncertain. Our objective was to determine the efficacy of a simple electronic monitoring device to maintain a SRP during MV. Patients and methods: We conducted a prospective, randomized, crossover study in two ICUs. During the CD, BE was managed according to an internal procedure published previously. During the PD, an electronic device developed by our institution was added to the bed.
The device was able to monitor continuously the BE and to alarm if the patient is not in the proper position. No period effect was identified. No adjustment covariate was significantly associated with the proportion of time spent in the SRP. Prospective studies are required to assess its clinical impact. Introduction: Ineffective triggering is frequent during pressure support ventilation PSV. Its occurrence is favored by dynamic hyperinflation that may arise when increasing the pressure support level PSL. Decreasing the PSL however fails to suppress ineffective triggering in a subgroup of patients that are therefore exposed to refractory ineffective triggering.
Patients and methods: Refractory ineffective triggering was defined as persisting ineffective triggering at the lowest tolerated PSL. Patients with refractory ineffective triggering during PSV were included. Continuous data are reported as median [25 th —75th percentiles]. Results: Seven patients with refractory ineffective triggering were included so far. Results with further inclusions will be presented. Introduction: An immediate coronary angiogram CAG may be associated with better outcome after out-of-hospital cardiac arrest OHCA in neurologically preserved patients but could be futile in other cases.
We aimed to assess the relationship between an immediate invasive strategy and survival after an out-of-hospital cardiac arrest OHCA of presumed cardiac cause, according to prognosis evaluated on hospital arrival. Early invasive strategy was independently associated with better survival in low-risk patients OR 2. Sensitivity analysis found consistent results. Conclusion: In cardiac arrest patients, our results suggest that the potential benefit of an early coronary angiogram and subsequent revascularization is restricted to those with a preserved neurological prognosis at hospital arrival.
Introduction: To our knowledge, no study mapped the epidemiology of unexpected cardiac arrest i. The current research primarily aims at describing the demographics, management, and prognosis of patients concerned. All victims of cardiac arrest during ICU stay are included, whereas patients presenting with cardiac arrest at the time of admission are not.
The data collected comprise medical history, circumstances of happening, ongoing treatments, resuscitation maneuvers, and outcome. A 6-month follow up period is planned for survivors. Results: Forty-four centers 17 University and 27 general hospitals are participating in the study, including 8 medical, 7 surgical and 29 medical surgical ICUs. Among those, nearly one-third have implemented a specific protocol regarding the management of cardiac arrest. On two-thirds of the investigation period, patients were victim of cardiac arrest in the participating units.
Conclusion: According to the Utstein style, our intermediate data are within the range reported in relevant literature. Although initial resuscitation was successful in two-thirds of cases, only Among other concerns, this study aims at determining among participating centers what specific interventions are likely to enhance prognosis and quality of life for cardiac arrest patients in the ICU. Introduction: Venous-to-arterial carbon dioxide difference cv-art CO 2 gap is a marker of tissue perfusion. Despite being in the security zone, high central venous oxygen saturation ScvO 2 is associated with poor outcome in patients with septic shock.
The aim of this study is to assess the ability of the cv-art CO 2 gap to predict clinical worsening in patients with septic shock, according to ScvO 2. Patients and methods: We performed a multicentric prospective study in 3 ICUs. All consecutive patients with septic shock were included during the study period. Patients were assigned into three groups according to ScvO 2.
Associations between cv-art CO 2 gap and day mortality along with length-of-stay LOS were explored using linear regression and correlations. Results: Fifty-six patients were included. Conclusion: cv-art CO 2 gap is a parameter to assess the inadequacy of circulating blood flow in response to metabolic demand. Introduction: Context—Metabolic acidosis is commonly observed in critically ill patients.
Experimental studies suggested that acidosis by itself could impair vascular function but such hemodynamic effect has been poorly investigated in human. Objectives: To assess the relationship between metabolic acidosis severity and endothelial microvascular function. Patients and methods: Design, settings and patients: Prospective monocenter study. Endothelial microvascular response to acetylcholine iontophoresis was measured at admission H0 and after correction of metabolic acidosis H Endothelial response was strongly depressed below a pH at 7.
At H24, after rehydration and insulin infusion, clinical and biological disorders were fully corrected. Conclusion: We documented an endothelial dysfunction during metabolic acidosis in critically ill patients with diabetic ketoacidosis. Endothelial dysfunction recovered after acidosis correction. Introduction: The passive leg raising PLR test mimics a volume challenge and is based on the passive transfer of some venous blood from the legs toward the cardiac cavities when moving a patient from the semi-recumbent to a passive leg raised position.
Nevertheless, intra-abdominal hypertension IAH may increase the resistance to venous return through the inferior vena cava and may impede the PLR-induced increase in cardiac preload. The IAP bladder pressure was measured at different study steps. The PLR test was negative in all but one of them was positive false positive. The area under the receiver operating characteristic curve was 0. Conclusion: Intra-abdominal hypertension is responsible for false negatives to the PLR test.
Introduction: Acute mesenteric ischemia AMI has high mortality and intestinal resection rates. An intestinal stroke center based on a multimodal and multidisciplinary management focusing on intestinal viability was created in our center in January We aimed to study AMI patients and outcomes. Patients and methods: Single-center, observational and prospective study was carried out in our intestinal stroke center.
AMI was defined as an acute intestinal injury related to a splanchno-mesenteric insufficiency and without alternative diagnosis.
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All AMI patients underwent a computed tomography angiography. AMI were classified in occlusive atheroma, thrombosis, embolisms etc. Patients with post-AMI short bowel syndrome SBS , chronic mesenteric ischemia, aorta dissection anevrism and left ischemic colitis were not included. Predictive factors of intestinal resection and mortality were studied in uni- and multivariate analyses. Quantitative data were reported as medians range. Main etiologies of occlusive AMI were atheroma Intestinal resection was necessary in Such structure could serve as a model for multicentric studies and to improve at a large territorial scale the prognosis and the knowledge of AMI.
Adverse events associated with PP have been well described such as pressure sores. But although patients with moderate to severe ARDS had high mortality, had prolonged length of stay and were particularly exposed to central venous catheters CVC , there were no data reporting intravascular catheter-related infections ICRI. Patients and methods: In this retrospective bicentric observational study we compared two groups of adults, assigned The primary outcome was the incidence of catheter-related colonization in each group.
The number and length of catheter did not differ significantly between groups. The incidence of CVC colonization was The odds ratio for PP was 3. In our study, PP was associated with a higher rate of colonization. The overall catheter-related infectious risk was affected by the PP. We probably identified a population at high risk of ICRI who may benefit from additional preventive measures.
Introduction: This study was designed to assess the effect of two extracorporeal life support ECLS blood-flow strategy in an experimental model of E-CPR in the first six hours of resuscitation on macrocirculatory and microcirculatory parameters, lactate clearance and cytokine storm. Patients and methods: Cardiac arrest was induced in 18 pigs by surgical ligature of the left coronary artery.
Continuous systemic blood pressure and carotid blood flow were continuously monitored.
Blood gas analysis and lactate were measured at baseline H0, H3 and H6. Lactate and sublingual microvascular parameters were significantly impaired after the low-flow period. Total infused norepinephrine and total infused fluid were similar between the two groups. Conclusion: In an experimental porcine model of refractory cardiac arrest treated by ECLS, a low-blood-flow strategy during the first six hours of resuscitation was associated with a decreased cerebral blood flow, lactate clearance and microcirculatory parameters despite a lower inflammatory response.
Most frequently, supportive treatments are unable to control this shock that may provoke multiple organ failure and death. We evaluated whether an early plasma removal of inflammatory mediators using high permeability hemodialysis HPHD in addition to conventional treatments could improve hemodynamic status of this patients. Patients and methods: We performed a randomized open-label trial. The control group received continuous veno-venous hemofiltration CVVH if needed.
Non-parametric tests were used to compare the two groups. The primary outcome was the duration of the shock expressed by the length of catecholamine infusion. Number of vasopressors-free days, 6-h repeated measures of blood pressure, daily fluid balance and mortality ICU and day have been evaluated as well. Results: 35 patients were included: 17 median age Baseline characteristics did not differ between the two groups.
Ventricular fibrillation was the first recorded rhythm in Day mortality rate was Number of catecholamine-free days was No difference was observed regarding the daily-dose of vasopressors and the 6-h recorded systolic mean diastolic arterial pressure. No difference in terms of fluid balance was observed either. Conclusion: In post-cardiac patients with acute circulatory failure, HPHD did not reduced the duration of shock and had no effect on hemodynamic status. Introduction: Reducing the use of broad-spectrum antibiotics in the ICU is a key issue. The P55 pneumonia cartridge of the multiplex-PCR Unyvero Curetis system allows identification of 19 bacteria and 1 fungi among the most frequently responsible for ventilator-associated pneumonia VAP , and 19 of their resistance markers directly in clinical specimens.
We aimed to evaluate the concordance between this technique and the conventional microbiological methods CMM for the diagnosis of VAP, assuming that it could support a decrease in broad-spectrum antibiotics consumption. Patients and methods: Prospective, observational, single centre study. All consecutive patients with suspected VAP and a positive direct examination of broncho-alveolar lavage fluid i.
We compared the results given by the 2 techniques, CMM being considered as the reference. Microorganisms responsible for VAP were predominantly P. Excluding Pa VAP, and assuming that the Unyvero system had been used for choosing initial empirical treatment, it could have saved a median of 2 [2—3] days of broad-spectrum antibiotics in 24 patients, but with a potential inappropriate initial antimicrobial treatment in 2 patients 2 with ESBL not detected.
Interventional studies are warranted to test the usefulness of this technique in an antimicrobial stewardship program. Acknowledgment: Curetis GmbH provided the P55 cartridges. Introduction: Hemophagocytic lymphohistiocytosis HLH is a rare yet life-threatening condition characterized by an inappropriate activation of lymphocytes and or histyocytes leading to an abnormal phagocytosis of blood cells.
Prognosis and outcomes mainly depend on the precocity of diagnosis and specific treatment implementation. The Purpose of the study was to describe epidemiological, clinical, paraclinical and therapeutic characteristics of HLH in ICU patients. We included all patients who had evidence of hemophagocytosis in bone marrow smears realized when HLH was suspected and a H-score superior to Results: The mean age of our patients was Hypertension and diabetes were the most frequent comorbidities.
Immunodepression was present in 5 patients. Shock and neurological disorders were the main causes of admission in ICU. Fever was the most common clinical presentation in SAM. The most common biological disorder was bicytopenia anemia and thrombopenia. The mean H-score was Hemodynamic and respiratory distress were the prevalent organ failures. Etoposid was taken by one patient. Infections were the largely predominant etiology of HLH with a clear prevalence of multidrug resistant bacterial infections. Septic shock was the leading cause of death.
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Conclusion: Management a patient with HLH is challenging because of its rarity, its variable presentation and its association with a panel of disorders. A multidisciplinary approach is mandatory to determine the best therapeutic option for the patient. Neverthless, RBC transfusions are associated with increased morbidity and mortality. This could suggest to combine [Hb] and some parameters reflecting the sytemic DO2 VO2 balance to decide to transfuse.
This study aims to analyse the effects of RBC transfusion on the systemic oxygenation assessed by the central venous oxygen saturation S c VO2 , the lactate level, the venous-to-arterial carbon dioxyde pressure gradient Pv-aCO2 and the ratio between cardiac index and O 2 extraction IC EO2 , and to assess their usefulness in the transfusion decision. The systemic oxygenation parameters have been measured before and after transfusion. The results are expressed in median and interquartile ranges. Comparisons were made by a Wilcoxon test.
Results: 86 RBC transfusions were made on 53 patients. For all patients, mean arterial pressure, [Hb] and S c VO2 increased significantly after transfusion [Hb]: 7. These results are maintained whatever the cardiac or septic status. It should be interesting to combine it with the [Hb] in the decision to transfuse anemic critically ill patient. Introduction: There is very little data on the survival of elderly patients with cancer requiring admission to intensive care unit ICU. In case of multiple admissions only the 1st admission was used for the statistical analyses.
Median survival after discharge from hospital was 7. The identified prognostic factors for higher hospital mortality were non invasive ventilation use OR 9. Life-sustaining therapeutic limitation is directly related to hospital mortality and post-discharge survival. Introduction: Studies assessing outcomes of CNS infections in critically ill immunocompromised patients are scarce. We sought to describe clinical features and outcomes in this population. Patients and methods: We conducted a retrospective observational study over a year period 01, —08, All patients admitted to the ICU, presenting with meningitis, encephalitis or brain abscess were included.
All patients with the following diseases were considered: hematologic malignancy, solid tumor, solid organ transplantation, autoimmune disease and splenectomy. HIV patients were not included. Conclusion: This study sheds light on clinical features and outcomes in immuncompromised patients with CNS infections. Determinants of mortality and comparative data across the main groups of CNS infections are being prepared.
Introduction: Cardiac involvement in patients with TTP is associated with high mortality. It might be undermined by the lack of operational definition and established diagnostic workup for cardiac TTP. The objectives of this study were to describe cardiac involvement in TTP patients and to assess prognostic value of each clinical sign.
Cardiac signs included chest pain, changes in electrocardiogram, increase troponin level, new-onset changes in cardiac echography, cardiogenic shock, cardiac arrest. Half the TTP were idiopathic, 25 autoimmune, 5 drug-related and 4 surrounded pregnancies. All patients received urgent plasma therapy with a median number of plasma exchanges of 11 8—18 and all but 3 received steroids, including 28 who received bolus.
Troponin was the only feature of cardiac involvement in 24 patients. In 13 patients, echocardiography identified focal or global hypokinesia. Anticoagulants were prescribed in 86 patients 58 prophylactic and 28 curative and 88 patients received low dose aspirin. Hospital mortality was 9. All the 9 patients without cardiac involvement survived.
Cardiac involvement was associated with prolonged ICU stay 6 4—7 vs. By univariable analysis, factors associated with mortality included age, platelet count, status epilepticus, troponin level, cardiac arrest. Introduction: The use of alternatives to carbapenems to treat patients with extended-spectrum beta lactamase-producing Gram negative bacilli ESBL-GNB infections remains controversial.
Their use in patients with severe infections in the ICU has been poorly studied. The aim of this study was to compare the outcome of ICU patients having received carbapenems to those having received a carbapenem-sparing agent CSA. Patients treated with betalactam betalactam inhibitor BL BLI , cefepime or quinolones were considered has having received an alternative to carbapenems CSA.
Patients having received such a CSA were compared to those having received a carbapenems. Primary outcome was treatment failure at day 28, defined as ESBL-GNB infection recurrence relapse with same pathogen or death, whichever first occurred. Source of infection was the lung for most of them.
Among the 26 patients having received a non-carbapenem agent as empirical treatment, pathogen was susceptible to this agent in 9 and they pursued the same treatment CSA-only group , whereas 17 were switched to a carbapenem pathogens resistant to empirical treatment, carbapenem-definite group. Globally, 27 patients received a CSA as their definite treatment CSA-definite and CSA-only groups , whereas 39 received a carbapenems carbapenems-only and carbapenems-definite groups. Whereas duration of antimicrobial treatment was similar 8 [6—10] days vs.
Larger studies are needed. Introduction: This study aimed to assess whether augmented renal clearance ARC impacts negatively on beta-lactam antibiotic unbound concentrations and clinical outcome in critically ill patients. Patients and methods: Over a 9-month period, all critically ill patients treated by beta-lactam antibiotics for a microbiologically documented infection without renal impairment were eligible. Results: Over the study period, 96 patients were included. MIC was independently associated with therapeutic failure with an OR at 5. MIC with an OR at 5. MIC was associated with higher rates of therapeutic failure.
This study emphasizes the need of therapeutic drug monitoring in patients with ARC, especially when targeting less susceptible pathogens or surgical infections with limited penetration of antimicrobial agents. Whether those patients should benefit for increased dosing regimens should be evaluated by randomized controlled studies.
Introduction: Critically-ill patients often receive antimicrobials. Early adequate antibiotic administration, usually including beta-lactams, improves prognosis of septic patients. However, beta-lactam pharmacokinetic as well as effect of renal replacement therapy RRT on beta-lactam concentrations have been hardly explored in ICU patients with acute kidney injury AKI.
We aimed to determine factors associated with potential suboptimal beta-lactam concentration in critically-ill patients with AKI treated either with an early or a delayed RRT strategy. The appropriate concentration was defined as a trough of at least 4 times the minimal inhibitory concentration clinical breakpoint of EUCAST. Results: Among the patients included in the 11 centers participating to this ancillary study, a beta-lactam trough concentration was evaluated in subjects, 53 in the early and 59 in the delayed groups.
Ninety patients In contrast, only 10 of the 16 patients without definite sepsis Multivariate analysis will be presented. Interestingly, RRT initiation strategy was not associated with beta-lactam trough concentration. Early RRT did not affect trough concentration of beta-lactam. We may hypothesize that physicians were highly vigilant and adapted antibiotic administration adequately in these patients. Membrane sequestration, alteration of the volume of distribution and lack of data in this population make drugs pharmacokinetics PK on ECMO challenging.
Our study aimed to assess the prevalence of insufficient Amikacin C max in critically ill patients on ECMO and to identify relative risk factors. Patients and methods: Prospective, observational, monocentric study of adult patients on venoarterial VA or venovenous VV ECMO receiving a loading dose of Amikacin for suspected Gram-negative infections. Conclusion: This large prospective study suggests that the prevalence and associated risk factors of Amikacin under-dosing are similar in critically-ill patients with or without ECMO.
Intensive Care Med. Introduction: Delirium is frequent in the ICU and has impact on morbidity and mortality. Broad-spectrum beta-lactams BL are daily used and may have neurological side effects, notably in cases of overdosing. Patients and methods: Prospective observational study—pilot study in two centers.
BL concentrations were measured at peak and trough for intermittent and extended perfusion, and at plateau for continuous perfusion, by high performance chromatography coupled with mass spectrometry. Statistical were performed by Mann—Whitney U test and Pearson test. Results: Fifty patients were included 29 with delirium, 21 controls , at day 4 for controls and day 5 for patients with confusion.
Discussion: Trend in association of BL overdosing with delirium corresponds to previous studies, and would need a larger scale study to be confirmed. Severity differences in groups would need changes in inclusion criteria to obtain homogeneous groups. A possible association of BL underdosing with poor evolution of infection and organ failures would need more precise evaluation. Hypoalbuminemia could have an impact on BL overdosing. Conclusion: Delirium was not associated with BL overdosing but with therapeutic index. A high variability of BL concentrations warrants therapeutic drug monitoring.
A larger scale study should include changes in design. The aim of this study was to assess the feasibility and safety of ECCO2R with a renal replacement platform RRT to permit ultra-protective ventilation in patients with mild to moderate acute respiratory distress syndrome ARDS. VT was gradually reduced from 6 to 5, 4. Complications, mortality at day 28, need for adjuvant therapies and data on weaning from both mechanical ventilation and ECCO2R were also collected. As a result, the driving pressure was significantly reduced to 7. Introduction: Protective lung ventilation PLV is recommended in patients with acute respiratory distress syndrome ARDS to minimize additional injuries to the lung.
However, increased right ventricular RV afterload resulting from ARDS could be enhanced by hypercapnic acidosis resulting from ventilation at lower tidal volume. Patients and methods: This study was performed in an experimental model of severe hypercapnic acidosis performed in 2 series of 6 pigs.
In the first group ARDS group , an ARDS obtained by repeated bronchoalveolar lavage was performed before reducing ventilation, while in the second group control group , hypercapnic acidosis was resulting from low tidal volume ventilation alone. Severe hypercapnic acidosis occurred in both groups: PaCO2 increased from Pulmonary vasoconstriction resulting from hypercapnic acidosis is strongly enhanced by factors like hypoxia, endothelial injuries or inflammatory mediators in ARDS.
Introduction: Prone positioning has been shown to improve mortality in acute respiratory distress syndrome ARDS patients. The respiratory system driving-pressure DPRS and the transpulmonary driving-pressure DPL , measured with esophageal manometry, have been shown to be strongly correlated with mortality. The aim of this study was to investigate the evolution of the DPL during prone positioning and its relationship with evolution of oxygenation in ARDS patients. Finally, we studied the correlation between these respiratory variables and oxygenation indicators.
Patients were classified as responders to prone positioning if the change in the ratio of arterial oxygen partial pressure oxygen inspired fraction Delta. Results: In the whole population, median value of Delta. In responders, DPL significantly decreased from 8. Other respiratory variables did not change. In non-responders, respiratory variables did not change. Between responders and non-responders, there was no significant difference between baseline respiratory variables. After prone positioning, Delta. On the contrary Delta. We did not find any correlation between Delta. The correlation between Delta.
Conclusion: In patients who respond to prone positioning by the highest improvement in oxygenation, DPL significantly decrease after prone positioning. Introduction: Whereas prone positioning PP has been shown to improve patient survival in moderate to severe ARDS patients, its rate of use was 7. However, Lung Safe study was not specifically focused on PP. Therefore, present study aimed to determine prevalence of use of PP in ARDS patients primary end-point , physiologic effects of and reasons for not using PP secondary end-points.
For patients with ARDS defined from the Berlin definition criteria at each study day oxygenation and ventilator settings were recorded. For those receiving PP these variables were recorded before and at the end of PP session. The reasons for not proning were also collected. Values are presented as median 1st—3rd quartiles. Prevalence rates of PP were compared by using Chi square for trend and groups were compared with nonparametric tests. Over the four study days, one-hundred and two ARDS patients received at least one proning session The prevalence of prone positioning in ARDS patients was not significantly different between study days: Over the four study days merged, the rate of PP use was 5.
The duration of the first PP session was 18 [16—23] hours. The main reason for not proning was not severe enough hypoxemia reasons for not proning ARDS patients, Introduction: Although acute respiratory distress syndrome ARDS has been largely focused on, few data are available concerning hypoxemia independently of its cause in intensive care unit ICU patients. Here, we describe the main etiologies, management and outcomes of the patients of this cohort presenting with severe hypoxemia. Hypoxemia was defined by a PaO2 FiO2 ratio below We analyzed the data from patients with severe hypoxemia i.
The main cause of hypoxemia was pneumonia and this diagnosis was more frequent than in mild and moderate hypoxemia. Whereas bilateral radiologic infiltrates were present in 56 Invasive mechanical ventilation MV was used in 55 High flow oxygen was administered in 11 Median Vt was 6. Positive end-expiratory pressure PEEP was higher than in mild and moderate hypoxemic patients 10 8—12 vs. Median plateau pressure was Neuromuscular blocking agents were administered in 28 Fourteen ICU mortality was higher in severe hypoxemic patients as compared to mild and moderate Even though ARDS might be underdiagnosed, a protective ventilation was respected in severe hypoxemic patients.
Introduction: Major changes in septic shock management raise the questions of the relevance of the classical risk factors of nosocomial infections in the current era and the link with the primary infectious insult. We herein investigated the risk factors and the outcomes of ICU-acquired infections in a recent cohort of septic shock patients.
Patients and methods: This was a 9-year — monocenter retrospective study. Septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. Patients who survived the first three days were eligible for assessment of the risk of the first ICU-acquired infections. The diagnosis of nosocomial infections were based on current international guidelines. Patients were classified according to the development of pulmonary or non-pulmonary ICU-acquired infections. The determinants of ICU-acquired infections were addressed in a multivariate logistic regression analysis.
Results: patients were admitted for septic shock. Hence, patients remained free of secondary infections, patients first developed an episode of nosocomial pneumonia and 96 patients first developed an episode of non-pulmonary infection. In multivariate analysis, the development of ICU-acquired pneumonia was independently associated with male gender OR 2. The development of non-pulmonary infections was independently associated with renal replacement therapy OR 4.
Conclusion: ICU-acquired pneumonia occurs preferentially in patients with septic shock of pulmonary origin. In addition, we identified the transfusion of blood products as a risk factor for pulmonary and non-pulmonary nosocomial infections. Introduction: Human serum albumin is used for the restoration of blood volume, emergency treatment of septic shock patients.
Several experimental studies suggested that albumin could have additional protective effects on the vascular wall and more specifically on endothelial functions. However, the in vivo effect of albumin in human endothelium remains unknown. The aim of this study is to assess the effect of albumin or saline infusion on skin endothelial function in septic shock patients requiring volume expansion. Patients and methods: We performed a prospective randomized monocentric study in an bed medical intensive care unit. All patients with septic shock who required fluid administration were included between H6 and H24 after vasopressor starting.
Endothelium-dependant vasodilatation in the skin circulation was assessed by iontophoresis of acetylcholine before and after fluid administration. The improvement of skin blood flow in response to acetylcholine after fluid administration was compared between groups. For each patient, age, sex, SAPS II, site of infection, global hemodynamic parameters and clinical microcirculatory parameters were recorded. Twelve patients received saline and 10 received albumin.
Apart from age, no statistical difference was found between groups regarding demographic characteristics and baseline hemodynamic parameters.
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Next, we compared the variations of endothelium response to iontophoresis before and after fluid infusion. Conclusion: In the early stage of septic shock resuscitation, we showed that albumin infusion had protective endothelial effects. This result has to be confirmed in a larger cohort. It is currently unclear what is the gold standard to detect SAE, how it can be prevented, and how evolution to long-term disability can be prevented.
The aims of this study were to determine which clinical scales are altered after sepsis and if acute encephalopathy is associated with short-term cognitive impairment. Patients and methods: We prospectively included adult patients with sepsis between January and September Exclusion criteria were encephalopathy from another etiology, psychiatric disorder, recent sepsis or cardiac surgery.
We assessed encephalopathy using a modified Synek scale. A healthy control group of 18 adults was used for comparison. Results: We enrolled 38 patients, all with EEG demonstrated encephalopathy. Encephalopathy was not associated with short-term cognitive function. Further study and a larger cohort are needed to determine which early EEG features can identify patients who will develop short-term and long-term cognitive dysfunction.
Introduction: Sepsis associated encephalopathy SAE is associated with increased morbidity and mortality. Its pathophysiology is incompletely elucidated but a possible impairment of cerebral autoregulation CAR could result in brain hypoperfusion and neuronal damage 1, 2. Patients and methods: We studied 96 adult patients with sepsis July —August Exclusion criteria were—intracranial disease; arrhythmias; extracorporeal membrane oxygenation; and any supra-aortic arteriopathy. ICU length of stay was 7[4—12] days.
Mxa was 0. Conclusion: CAR was altered in nearly half of the patients with sepsis. Mxa was higher in patients with than without SAE. Introduction: There is growing evidence that corticotherapy improves survival from septic shock. This observational study aimed at evaluating at bedside resistance to corticosteroids in adults with sepsis. We also evaluated 10 healthy controls. Intervention—resistance to corticosteroids was assessed using a skin test.
Discussion: Topic application of corticosteroids on the skin results in activation of glucocorticoid receptors present within the vessels. Subsequently, activation of lipocortin 1 may inhibit the activity of phospholipase A2, regulator of prostaglandins, leucotrienes and platelet activating factor. Then, the coupling of alpha adrenoreceptors to their agonists is potentiated, increasing vessels smooth muscles sensitivity to catecholamines.
The subsequent local vasocontriction is reflected by skin blanching. Thus, the observed lack of skin blanching in septic patients may reflect altered coupling between gluocorticoids and glucocorticoids receptors. Conclusion: Roughly one out of two adults with septic shock may develop a resistance to corticosteroids as assessed by a skin blanching test in response to betamethasone. Introduction: Mild therapeutic hypothermia, currently recommended in the management of cardiac arrests with shockable rhythm could promote infectious complications and especially ventilator-associated pneumonia VAP Mongardon et al.
Crit Care Med Resuscitation , systematic use of antibiotic prophylaxis is not recommended in patients treated with mild therapeutic hypothermia after cardiac arrest. Secondary objectives were its impact on incidence of late VAP and on Day 28 mortality. Patients and methods: Multicenter two parallel-group double-blinded randomized trial.
Adult patients hospitalized in ICU, mechanically ventilated after out-of-hospital resuscitated cardiac arrest related to initial shockable rhythm and treated with mild therapeutic hypothermia were eligible. Exclusion criteria were pregnancy, need for extracorporeal life support, ongoing antibiotic therapy or pneumonia, known chronic colonization with multiresistant bacteria, known allergy to beta-lactam antibiotics and moribund patients.
The primary endpoint was the onset of early VAP. All suspected pulmonary infections were adjudicated by a blinded independent committee. Results: Out of patients included, were finally analyzed, 99 in treatment group and 97 in placebo group mean age Day 28 mortality was similar in both arms Conclusion: Short-term antibiotic prophylaxis with amoxicillin-clavulanic acid significantly decreases incidence of early VAP in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest related to shockable rhythm.
Introduction: Immunosuppressed IS patients are prone to develop respiratory failure and to need ventilatory support. Invasive ventilation shared a grim prognosis in the past and non-invasive ventilation had been recommended in these patients, however NIV efficacy has been recently challenged and the advent of high flow oxygen therapy had brought even more complexity in the management of such patients.
Using the data from a recent point-prevalence-day of hypoxemia in ICU, we compare the frequency, management and outcomes of hypoxemia in IS and immuncompetent IC patients. We focused on the causes of hypoxemia, the ventilatory management and the outcome. The causes of hypoxemia were also similar pneumonia being the leading cause.
Respiratory support used in hypoxemic IS patients was ambient air in 3, low flow oxygen in 24, high flow in 11, NIV in 5 and invasive ventilation in 56 patients, with a different distribution from the IC patients more patients on high flow therapy and less invasively ventilated. Oxygenation management is slightly different from immunocompetent patients with more frequent use of high flow therapy. Introduction: HFNC is currently proposed as first-line respiratory support in moderate to severe acute viral bronchiolitis AVB in infants.
The primary endpoint was the percentage of failure, defined as the occurrence of one or more of the following—increase in mWCAs or RR, increase in discomfort EDIN score , and severe apnea episodes. Results: infants with mean SD age and weight of 47 58 days and g were included from November to March No difference was observed between groups for baseline characteristics. Failure rate was not different between groups— No center effect was observed for failure.
Patients and methods: Multicenter, double-blind, randomized trial in 8 french ICU. Dobutamine was introduced at the physician discretion according to a combination of parameters—echocardiographic parameters, cardiac index, lactate clearance, SVO2 and Swan-Ganz derived parameters. There were no differences in the duration nor in the maximal dose or cumulated dose of epinephrine or norepinephrine. There were no differences in the duration, in the maximal or cumulated dose. Arterial pressure evolution was similar.
Heart rate increased significantly in epinephrine group and did not change in norepinephrine group. Cardiac index and cardiac power index increased significantly more in the epinephrine group than in the norepinephrine group. Cardiac double product, a surrogate of myocardial oxygen consumption increased in epinephrine group and did not change in norepinephrine group.
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Conclusion: In patients with cardiogenic shock following myocardial infarction, epinephrine use was associated with a lactic acidosis, an higher incidence of refractory shock and an increased risk of death plus ECMO at J7. Introduction: Superantigen toxins synthesized by S. High dose intravenous immunoglobulins IVIG , able to neutralize these toxins, are frequently used even tough evidence of its efficacy is not supported by randomized controlled study RCT.
Moreover, IVIG are expensive and possibly harmful. Before conducting a RCT, a pilot study was first designed to assess the feasibility in the context of pediatric critical care. Secondary objectives were to assess the efficacy of IVIG on organ dysfunction using Pelod-2 score , on mortality at day 60 and their safety. Inform consent from both parents was required before randomization. This study was funded by CSL-Behring company. The blinding was well respected. The eCRF completion was judged easy by investigators. The treatment delivery had to be improved, requiring the help of research assistants.
Seven serious and one severe adverse events were registered, all patients recovered and no death was reported. Conclusion: This pilot study suggested that a RCT is feasible. It provides crucial information to improve the recruitment, the respect of the protocol and the correct measure of organ failure. However, inclusion of international centers is necessary to attain the sample size required. Introduction: Indirect calorimetry is a non invasive tool to measure oxygen consumption VO 2 and resting energy expenditure at bedside.
The aim of the present study was to assess the validity of the indirect calorimetry-based method for the work of breathing assessment when compared to esophageal pressure Pes measurement and Electrical Activity of the Diaphragm EAdi during a spontaneous breathing trial in continuous positive airway pressure. Patients and methods: A prospective single center study. Patients considered as ready to extubate were included. Simultaneous recordings of VO2, Pes and EAdi were performed during 3 steps: before, during and after the spontaneous breathing test in continuous positive airway pressure.
Results: Twenty patients, median 5. Half of the patients were admitted for a respiratory reason. The same trend was observed in respiratory drive, assessed by EAdi which increased from 7. Oxygen consumption obtained by IC was higher during spontaneous breathing test as compared to conventional ventilation 3. Changes in work of breathing as assessed by VO 2 was poorly correlated with measurements from Pes and EAdi whereas we found a moderate correlation between Pes and EAdi values.
Conclusion: During weaning from mechanical ventilation, spontaneous breathing test in continuous positive airway pressure induced an increase in work of breathing, both in respiratory drive, as measured by EAdi and in respiratory mechanics, as measured by Pes. Oxygen consumption measured by Indirect Calorimetry does not seem to be a reliable tool to assess work of breathing in mechanically ventilated children.
We conducted this second phase to evaluate the potential impact of actions to promote breastfeeding on unwanted weaning during hospitalization for bronchiolitis. Patients and methods: This is a cross sectional study during two epidemic seasons of bronchiolitis in a tertiary care hospital. Patients discharged at home whose parents accepted to be contacted by phone were included.
A bundle of actions to promote breastfeeding in patients with bronchiolitis was implemented posters, flyers, staff training, equipment with breast pumps between the two epidemic seasons. The data was extracted from the charts and from a phone survey two weeks after discharge to evaluate breastfeeding in eligible patients in our hospital. Phase I before action had included 84 patients hospitalized between December and March in all wards hosting patients with bronchiolitis. Phase II after action included 50 patients hospitalized from October to December The data from phase II was compared with data from phase I.
Conclusion: Bronchiolitis is a high risk event for breastfeeding disruption but staff training and correct advices and support for mothers during hospitalization seems to diminish that risk. Statistical analysis included proportions, correlations and Bland—Altman analysis. Approximately 46 million rows were retrieved from the databases including 19, PaO2 values. The accuracy is probably in favor of the HTR because of the shorter time-lapse between the OI parameters.
Adult studies showed alteration of distribution and elimination which can lead to insufficient drug concentration in septic patients. In children, studies are lacking and antibiotic dosing may be suboptimal. We aim to describe the plasma concentration of the most used beta-lactam in critically ill children, to describe the rate of patients with suboptimal exposure and associating clinical and biological factors.
Beta-lactam plasma concentrations were analysed using High Performance Liquid Chromatography. Bacteria were identified in 26 patients Twenty-four patients Conclusion: In conclusion, current standard beta-lactam dosing in children with severe sepsis or septic shock could be inadequate to reach the target concentrations. That could lead to the risk of clinical and bacteriological failures as well as the emergence of bacterial resistance.
Further pharmacokinetic studies are mandatory to improve antibiotic therapy in this vulnerable population. Introduction: Intermittent hemodialysis is a key support therapy in ICU. Despite protocol-based optimization, intradialytic hemodynamic instability IHI remains a common complication and could account for mortality and delayed renal recovery.
The identification of patients at high risk for IHI is crucial but remains poorly explored. Our objective was to test whether tissue perfusion parameters assessed at the bedside mottling, index capillary refill time iCRT , and lactate predict IHI and to develop and to validate a predictive score of IHI. Patients and methods: Prospective observational study in a bed medical ICU in a tertiary university hospital including hemodialysis sessions performed for acute kidney injury.
Exclusion criteria were patients with dark skin and dialysis performed in extreme emergency. Results: Ninety-six hemodialysis sessions performed in 43 patients were recorded. A threshold of 4. The accuracy of this score was validated in a second prospective cohort including hemodialysis sessions performed in 45 patients.
At the bedside, a combined tissue hypoperfusion score including mottling score, iCRT and lactate level is helpful to identify patients at high risk of IHI. Introduction: Epidemiological data suggest an increased risk of long-term chronic kidney disease after acute kidney injury AKI. In survivors of out-of-hospital cardiac arrest OHCA , AKI is frequent and is associated with numerous factors of definitive renal injury. Long-term creatinine level was the last blood creatinine assessment we were able to retrieve. Long-term mortality was evaluated as well. Results: Among the OHCA patients who were discharged alive, we were able to retrieve the outcome of patients median age 55 [iqr 46, 68], During a median follow-up time of 1.
In several countries, epidemiology of AKID is lacking. Patients and methods: The study was conducted using the French database on hospitalizations Program of Medicalization of Information Systems. It focused on adults hospitalized in metropolitan France between and and diagnosed with AKID according to the codes of Common Classification of Medical Procedures.
We described and statistically compared crude and standardized incidence of AKID on gender and age, as well as comorbidity and mortality rates, principal diagnosis and dialysis modality. We also analyzed variables associated with mortality using logistic regression. Results: Crude incidence of AKID increased from per million people pmp in 16, cases to pmp 25, cases in The most common comorbidities were cardiocerebrovascular The five most frequent principal diagnoses were heart failure Number of stays in intensive care units increased from Continuous dialysis was the most widely used dialysis modality, with a utilization rate up from Factors associated with higher mortality were: advanced age, intensive care admission OR 3.
Introduction: Many critically ill patients have a moderate to high risk of bleeding but they also require prolonged intermittent dialysis to ensure a negative water balance without hemodynamic adverse events. We assessed the safety and efficiency of heparin-free regional citrate anticoagulation of the dialysis circuit using a calcium-free citrate-containing dialysate, with calcium reinjected according to ionic dialysance an online measure of the instantaneous clearance of small molecules available in most of dialyzers.
Patients and methods: We prospectively reported the clotting events that occurred during all the heparin-free dialysis sessions that were performed with a regional anticoagulation based on calcium-zero citrate-containing dialysate Citrasate, Hemotech, France between January and August in a beds ICU. When assessed, urea and Beta2-microglobulin reduction rates were Postfilter ionized calcium was 0.
A major clotting event that led to premature termination of the session occurred in only sessions 2. In these five cases, major catheter dysfunction occurred before clotting within the circuit. In 85 sessions, no ionized calcium measurement was required. Conclusion: Dialysis anticoagulation with calcium-free citrate containing dialysate is an easy-to-use, efficient, and inexpensive form of heparin-free regional anticoagulation.
Calcium reinjection according to ionic dialysance allows prolonged hemodialysis sessions in critically ill patients without the need to systemically monitor ionized calcium. Sessions can be safely extended according to the hemodynamic tolerance to ensure an adequate dose of dialysis and a negative water balance, a major point in patients with severe AKI.
Superimposed AKI on chronic kidney disease CKD is associated with long-term risk of death and end-stage renal disease. The primary endpoint was day mortality. Secondary endpoints included—number of patients who actually received RRT, RRT-free days, mechanical ventilation-free days and vasopressor-free days, ICU and hospital length of stay, time to renal function recovery, day and day dependence on RRT.
The number of vasopressor-free days was significantly higher in patients with CKD assigned to the delayed strategy 5. Conclusion: Early renal replacement therapy initiation strategy was associated with a significant increase in day mortality in the subgroup of patients with CKD. Introduction: Brain injury is the first cause of death after cardiac arrest CA and multimodal neuroprognostication is a cornerstone of post-resuscitation care.
Among the different usable information provide by electroencephalogram EEG , the aim of this study was to evaluate the predictive value of EEG reactivity regarding neurological outcome at discharge.
In addition to usual clinical findings, we collected EEG patterns and reactivity, status epilepticus and somatosensory evoked potentials characteristics. The EEG reactivity was evaluated by a blinded neurophysiologist and was defined as a reproducible change of the tracing in amplitude or frequency provoked by an auditory and a nociceptive standardized stimulation.
We evaluated the predictive values of persistent lack EEG reactivity and other indicators regarding their respective ability to predict a favorable or unfavorable outcome. First Edition. Very good paperback copy; edges somewhat slightly dust-dulled and nicked. Remains particularly well-preserved overall; tight, bright, clean and strong. Notes; Facsimile of the original text, parallel English translation. Limited ed. Subject; Gozo Island Malta Description and travel. More information about this seller Contact this seller 5. Published by Naaman, Sherbrooke Quebec About this Item: Naaman, Sherbrooke Quebec, This edition presents the complete text of Baron Taylor's letters, based on the manuscripts.
We have respected usages, particularities, and caprices of orthography and punctuation, often without using the traditional [sic]. Words underlined in the original have been reproduced in italics. A correct text and exact punctuation are easy to reconstruct. More information about this seller Contact this seller 6. More information about this seller Contact this seller 7. Voyage philosophique et pittoresque en Angleterre et en France fait en , suivi d'un Essai sur l'histoire des arts dans la Grande-Bretagne, par George Forster, l'un des compagnons de Cook.
Traduit de l'allemand. More information about this seller Contact this seller 8. Published by Albin Michel, Paris About this Item: Albin Michel, Paris, Edition originale. Bon exemplaire. More information about this seller Contact this seller 9. Couverture souple. Condition: Bon. Des rousseurs, un infime manque angulaire en couverture. Dos refait. More information about this seller Contact this seller Published by DROZ From: Librairie de Boccard Paris, France.
Couverture rigide. Condition: Neuf. Published by Alfred Cattier, Tours. About this Item: Alfred Cattier, Tours. Soft Cover. Condition: Good. No jacket. Premiere edition. Alfred Cattier. Sans date. Plats originals mais un peu sales. Published by Furne et Ce. About this Item: Furne et Ce.
Quarter Leather. No Jacket. Boilly, Jules illustrator. Possible First Edition. Marbled boards, tan leather. Boards edgeworn and scuffed. Binding otherwise secure. Page edges browned, some small marginal marks and a little scattered foxing but otherwise internally unmarked. Title and first pages creased see image. No maps; pp and plates IX and X in En Asie misplaced during binding but all pp and plates present. French text. A worn but complete apart from the sadly missing maps early,?
Please note: this is a heavy book, shipping outside the UK will incur extra charge. Published by P. Plon et Cie, , 1 vol. About this Item: P. From: Hermann L. Strack Loguivy Plougras, France. About this Item: Library stamps. Seller Inventory TG Condition: Assez bon. Assez bon exemplaire. Seller Inventory L EyriesDate de l edition originale: Sujet de l ouvrage: Asie -- Descriptions et voyages -- 19e siecleAfrique -- Descriptions et voyages -- 19e siecleCe livre est la reproduction fidele d une oeuvre publiee avant et fait partie d une collection de livres reimprimes a la demande editee par Hachette Livre, dans le cadre d un partenariat avec la Bibliotheque nationale de France, offrant l opportunite d acceder a des ouvrages anciens et souvent rares issus des fonds patrimoniaux de la BnF.
Bound in red half sorrow, dosa five nerves, golden tail date, scratching head back, marbled paper plates, paper contreplats guards and to the tank. Illustrated work from sketches of Mr. Constant-Rebecque baron and author. Quite complete copy of its fine in-folding map.
Some spots. Published by A. Laplace Paris , Paris Denver, CO, U. About this Item: A. Laplace Paris , Paris, No illustrations. Published by Paris : Librairie Nouvelle About this Item: Paris : Librairie Nouvelle, Very good paperback copy. Spine bands and panel edges slightly dust-toned and rubbed as with age. Remains particularly well-preserved overall; tight, bright, clean and strong; 8vo 8" - 9" tall; pages; Description: p.
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