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De Jong A, Cossic J, Verzilli D, Monet C, Carr J, Conseil M, Monnin M, Cisse M, Belafia F, Molinari N, Chanques G, Jaber S. Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases. Intensive Care Med 2018; 44:1106-1114. [PMID: 29947888 DOI: 10.1007/s00134-018-5241-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/22/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status. METHODS We conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index ≥ 30 kg/m2) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90. RESULTS Three hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40-53) in the non-obese and 46% (95% CI, 36-56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9 ± 4.2 cmH2O) than in non-survivors (15.2 ± 5.2 cmH2O, p < 0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7 ± 4.5 cmH2O) and non-survivors (13.2 ± 5.1 cmH2O, p = 0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR = 1.04 (95% CI 1.01-1.07) for each point of increase], Crs [HR = 0.97 (95% CI 0.96-0.99) for each point of increase] and driving pressure [HR = 1.07 (95% CI 1.04-1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients. CONCLUSIONS Contrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.
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Affiliation(s)
- Audrey De Jong
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS, UMR 9214, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France
| | - Jeanne Cossic
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Daniel Verzilli
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Clément Monet
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Julie Carr
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Mathieu Conseil
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Marion Monnin
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Moussa Cisse
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Fouad Belafia
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Nicolas Molinari
- Department of Statistics, University of Montpellier Lapeyronie Hospital, UMR 729, MISTEA, Montpellier, France
| | - Gérald Chanques
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS, UMR 9214, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France
| | - Samir Jaber
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS, UMR 9214, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.
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Abstract
Nearly 160 million Americans are overweight, obese, or morbidly obese. Morbid obesity and its numerous comorbidities are threats to a person's health. Moreover, hospitalized individuals living with adiposity-based chronic conditions are at risk for certain immobility hazards. Many individuals who are morbidly obese look to metabolic surgery as a means for achieving sustainable weight loss. This article addresses critical care needs of people living with excess weight or weight maldistribution, along with specific needs of those undergoing metabolic surgery.
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Affiliation(s)
- Cheryl Holsworth
- Cheryl Holsworth is Senior Specialist Bariatric Surgery, Sharp Memorial Hospital, San Diego, California. Susan Gallagher is Senior Clinical Advisor, Celebration Institute Inc, 8790 Skyline Lane, Conroe, TX 77302
| | - Susan Gallagher
- Cheryl Holsworth is Senior Specialist Bariatric Surgery, Sharp Memorial Hospital, San Diego, California. Susan Gallagher is Senior Clinical Advisor, Celebration Institute Inc, 8790 Skyline Lane, Conroe, TX 77302
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Montravers P, Blot S, Dimopoulos G, Eckmann C, Eggimann P, Guirao X, Paiva JA, Sganga G, De Waele J. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med 2016; 42:1234-47. [PMID: 26984317 DOI: 10.1007/s00134-016-4307-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/04/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE The management of peritonitis in critically ill patients is becoming increasingly complex due to their changing characteristics and the growing prevalence of multidrug-resistant (MDR) bacteria. METHODS A multidisciplinary panel summarizes the latest advances in the therapeutic management of these critically ill patients. RESULTS Appendicitis, cholecystitis and bowel perforation represent the majority of all community-acquired infections, while most cases of healthcare-associated infections occur following suture leaks and/or bowel perforation. The micro-organisms involved include a spectrum of Gram-positive and Gram-negative bacteria, as well as anaerobes and fungi. Healthcare-associated infections are associated with an increased likelihood of MDR pathogens. The key elements for success are early and optimal source control and adequate surgery and appropriate antibiotic therapy. Drainage, debridement, abdominal cleansing, irrigation, and control of the source of contamination are the major steps to ensure source control. In life-threatening situations, a "damage control" approach is the safest way to gain time and achieve stability. The initial empirical antiinfective therapy should be prescribed rapidly and must target all of the micro-organisms likely to be involved, including MDR bacteria and fungi, on the basis of the suspected risk factors. Dosage adjustment needs to be based on pharmacokinetic parameters. Supportive care includes pain management, optimization of ventilation, haemodynamic and fluid monitoring, improvement of renal function, nutrition and anticoagulation. CONCLUSIONS The majority of patients with peritonitis develop complications, including worsening of pre-existing organ dysfunction, surgical complications and healthcare-associated infections. The probability of postoperative complications must be taken into account in the decision-making process prior to surgery.
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Affiliation(s)
- P Montravers
- APHP, CHU Bichat-Claude Bernard, Département d'Anesthésie Réanimation, Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - G Dimopoulos
- Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
| | - C Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Peine, Germany
| | - P Eggimann
- Department of Intensive Care Medicine and Burn Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - X Guirao
- Department of Endocrine and Head and Neck Surgery, Corporació Sanitaria del Parc Tauli, University Hospital, Sabadell, Barcelona, Spain
| | - J A Paiva
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - G Sganga
- Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy
| | - J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
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