Development and validation of a multivariable model predicting the required catheter dwell time among mechanically ventilated critically ill patients in three randomized trials

BACKGROUND

The anatomic site for central venous catheter insertion influences the risk of central venous catheter-related intravascular complications. We developed and validated a predictive score of required catheter dwell time to identify critically ill patients at higher risk of intravascular complications.

METHODS

We retrospectively conducted a cohort study from three multicenter randomized controlled trials enrolling consecutive patients requiring central venous catheterization. The primary outcome was the required catheter dwell time, defined as the period between the first catheter insertion and removal of the last catheter for absence of utility. Predictors were identified in the training cohort (3SITES trial; 2336 patients) through multivariable analyses based on the subdistribution hazard function accounting for death as a competing event. Internal validation was performed in the training cohort by 500 bootstraps to derive the CVC-IN score from robust risk factors. External validation of the CVC-IN score were performed in the testing cohort (CLEAN, and DRESSING2; 2371 patients).

RESULTS

The analysis was restricted to patients requiring mechanical ventilation to comply with model assumptions. Immunosuppression (2 points), high creatinine > 100 micromol/L (2 points), use of vasopressor (1 point), obesity (1 point) and older age (40-59, 1 point; ≥ 60, 2 points) were independently associated with the required catheter dwell time. At day 28, area under the ROC curve for the CVC-IN score was 0.69, 95% confidence interval (CI) [0.66-0.72] in the training cohort and 0.64, 95% CI [0.61-0.66] in the testing cohort. Patients with a CVC-IN score ≥ 4 in the overall cohort had a median required catheter dwell time of 24 days (versus 11 days for CVC-IN score < 4 points). The positive predictive value of a CVC-IN score ≥ 4 was 76.9% for > 7 days required catheter dwell time in the testing cohort.

CONCLUSION

The CVC-IN score, which can be used for the first catheter, had a modest ability to discriminate required catheter dwell time. Nevertheless, preference of the subclavian site may contribute to limit the risk of intravascular complications, in particular among ventilated patients with high CVC-IN score. Trials Registration NCT01479153, NCT01629550, NCT01189682.

The association of prior paracetamol intake with outcome of very old intensive care patients with COVID-19: results from an international prospective multicentre trial

BACKGROUND

In the early COVID-19 pandemic concerns about the correct choice of analgesics in patients with COVID-19 were raised. Little data was available on potential usefulness or harmfulness of prescription free analgesics, such as paracetamol. This international multicentre study addresses that lack of evidence regarding the usefulness or potential harm of paracetamol intake prior to ICU admission in a setting of COVID-19 disease within a large, prospectively enrolled cohort of critically ill and frail intensive care unit (ICU) patients.

METHODS

This prospective international observation study (The COVIP study) recruited ICU patients ≥ 70 years admitted with COVID-19. Data on Sequential Organ Failure Assessment (SOFA) score, prior paracetamol intake within 10 days before admission, ICU therapy, limitations of care and survival during the ICU stay, at 30 days, and 3 months. Paracetamol intake was analysed for associations with ICU-, 30-day- and 3-month-mortality using Kaplan Meier analysis. Furthermore, sensitivity analyses were used to stratify 30-day-mortality in subgroups for patient-specific characteristics using logistic regression.

RESULTS

44% of the 2,646 patients with data recorded regarding paracetamol intake within 10 days prior to ICU admission took paracetamol. There was no difference in age between patients with and without paracetamol intake. Patients taking paracetamol suffered from more co-morbidities, namely diabetes mellitus (43% versus 34%, p < 0.001), arterial hypertension (70% versus 65%, p = 0.006) and had a higher score on Clinical Frailty Scale (CFS; IQR 2-5 versus IQR 2-4, p < 0.001). Patients under prior paracetamol treatment were less often subjected to intubation and vasopressor use, compared to patients without paracetamol intake (65 versus 71%, p < 0.001; 63 versus 69%, p = 0.007). Paracetamol intake was not associated with ICU-, 30-day- and 3-month-mortality, remaining true after multivariate adjusted analysis.

CONCLUSION

Paracetamol intake prior to ICU admission was not associated with short-term and 3-month mortality in old, critically ill intensive care patients suffering from COVID-19.

TRIAL REGISTRATION

This prospective international multicentre study was registered on ClinicalTrials.gov with the identifier "NCT04321265" on March 25, 2020.

Noninvasive ventilation in COVID-19 patients aged ≥ 70 years-a prospective multicentre cohort study

BACKGROUND

Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV.

METHODS

This is a substudy of COVIP study-an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality.

RESULTS

Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36-5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06-2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI - 2.27 to - 0.46 days) compared to primary IMV group (n = 1876).

CONCLUSIONS

Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV. Clinical Trial Registration NCT04321265 , registered 19 March 2020, https://clinicaltrials.gov .

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

Ability of procalcitonin to distinguish between bacterial and nonbacterial infection in severe acute exacerbation of chronic obstructive pulmonary syndrome in the ICU

Background

To assess the ability of procalcitonin (PCT) to distinguish between bacterial and nonbacterial causes of patients with severe acute exacerbation of COPD (AECOPD) admitted to the ICU, we conducted a retrospective analysis of two prospective studies including 375 patients with severe AECOPD with suspected lower respiratory tract infections. PCT levels were sequentially assessed at the time of inclusion, 6 h after and at day 1, using a sensitive immunoassay. The patients were classified according to the presence of a documented bacterial infection (including bacterial and viral coinfection) (BAC + group), or the absence of a documented bacterial infection (i.e., a documented viral infection alone or absence of a documented pathogen) (BAC- group). The accuracy of PCT levels in predicting bacterial infection (BAC + group) vs no bacterial infection (BAC- group) at different time points was evaluated by receiver operating characteristic (ROC) analysis.

Results

Regarding the entire cohort (n = 375), at any time, the PCT levels significantly differed between groups (Kruskal–Wallis test, p < 0.001). A pairwise comparison showed that PCT levels were significantly higher in patients with bacterial infection (n = 94) than in patients without documented pathogens (n = 218) (p < 0.001). No significant difference was observed between patients with bacterial and viral infection (n = 63). For example, the median PCT-H₀ levels were 0.64 ng/ml [0.22–0.87] in the bacterial group vs 0.24 ng/ml [0.15–0.37] in the viral group and 0.16 ng/mL [0.11–0.22] in the group without documented pathogens. With a c-index of 0.64 (95% CI; 0.58–0.71) at H₀, 0.64 [95% CI 0.57–0.70] at H₆ and 0.63 (95% CI; 0.56–0.69) at H₂₄, PCT had a low accuracy for predicting bacterial infection (BAC + group).

Conclusion

Despite higher PCT levels in severe AECOPD caused by bacterial infection, PCT had a poor accuracy to distinguish between bacterial and nonbacterial infection. Procalcitonin might not be sufficient as a standalone marker for initiating antibiotic treatment in this setting.

Ultraprotective ventilation allowed by extracorporeal CO2 removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study

Background

Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO₂ removal (ECCO₂R) might allow ultraprotective ventilation with lower tidal volume (V_T) and plateau pressure (P_plat). This study investigated whether ECCO₂R therapy could affect RV function.

Methods

This was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO₂/FiO₂ ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with V_T at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCO₂R device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol.

Results

The efficacy of ECCO₂R facilitated an ultraprotective strategy in all 18 patients included. We observed a significant improvement in RV systolic function parameters. Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm; p < 0.05). Systolic excursion velocity (S’ wave) also increased after the 1-day protocol (from 13.8 m/s to 15.1 m/s; p < 0.05). A significant improvement in the aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed (p = 0.05). There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP) and RV preload.

Conclusion

Low-flow ECCO₂R facilitates an ultraprotective ventilation strategy thatwould improve RV function in moderate-to-severe ARDS patients. Improvement in RV contractility appears to be mainly due to a decrease in intrathoracic pressure allowed by ultraprotective ventilation, rather than a reduction of PaCO₂.

Subcostal versus transhepatic view to assess the inferior vena cava in critically ill patients

BACKGROUND

Evaluation of the inferior vena cava (IVC) is not always possible through the subcostal (SC) window.

METHODS

Inferior vena cava diameters measured by transhepatic (TH) and SC views were compared by Bland and Altman analysis.

RESULTS

131 patients were enrolled, including 88 (67%) under mechanical ventilation. The echogenicity was statistically poorer through the TH view in comparison with the SC view (P = .002). The correlation between the SC and TH views was good and better for respiratory variation than for end-expiratory or end-inspiratory diameter measurements (r = 0.86). Despite low bias, the limits of agreement were wide (-7.5 and 7.7 mm for end-expiratory diameter, -8.7 and 8.5 mm for end-inspiratory diameter, and -5.3 and 5.8 mm for respiratory variation). Complementary analysis showed that the concordance between the SC and the TH views was better when the IVC was distended. However, the limits of agreement remained broad.

CONCLUSIONS

Although feasible in almost all patients, the TH view does not provide better echogenicity in comparison with the SC view. Despite a good correlation with the SC view and a low bias, the limits of agreement were wide, especially when the IVC has an ellipsoidal shape, suggesting caution in the interpretation of data obtained by the TH view.

Long-term Quality of Life in Adult Patients Surviving Purpura Fulminans: An Exposed-Unexposed Multicenter Cohort Study

BACKGROUND

Long-term health-related quality of life (HR-QOL) of patients surviving the acute phase of purpura fulminans (PF) has not been evaluated.

METHODS

This was a French multicenter exposed-unexposed cohort study enrolling patients admitted in 55 intensive care units (ICUs) for PF from 2010 to 2016. Adult patients surviving the acute phase of PF (exposed group) were matched 1:1 for age, sex, and Simplified Acute Physiology Score II with septic shock survivors (unexposed group). HR-QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36) questionnaire, the Hospital Anxiety and Depression (HAD) scale, the Impact of Event Scale-Revised (IES-R), and the activity of daily living (ADL) and instrumental ADL (IADL) scales. The primary outcome measure was the physical component summary (PCS) of the SF-36 questionnaire.

RESULTS

Thirty-seven survivors of PF and 37 of septic shock were phone-interviewed at 55 (interquartile range [IQR], 35-83) months and 44 (IQR, 35-72) months, respectively, of ICU discharge (P = .23). The PCS of the SF-36 was not significantly different between exposed and unexposed patients (median, 47 [IQR, 36-53] vs 54 [IQR, 36-57]; P = .18). There was also no significant difference between groups regarding the mental component summary of the SF-36, and the HAD, IES-R, ADL and IADL scales. Among the 37 exposed patients, those who required limb amputation (n = 12/37 [32%]) exhibited lower PCS (34 [IQR, 24-38] vs 52 [IQR, 42-56]; P = .001) and IADL scores (7 [IQR, 4-8] vs 8 [IQR, 7-8]; P = .021) compared with nonamputated patients.

CONCLUSIONS

Long-term HR-QOL does not differ between patients surviving PF and those surviving septic shock unrelated to PF. Amputated patients have an impaired physical HR-QOL but a preserved mental health.

CLINICAL TRIALS REGISTRATION

NCT03216577.

Place de l’assistance circulatoire extracorporelle dans l’arrêt cardiaque réfractaire

Le bénéfice d’une réanimation cardiopulmonaire (RCP) extracorporelle en comparaison d’une réanimation conventionnelle sur la survie et le pronostic neurologique à long terme des patients victimes d’un arrêt cardiaque réfractaire reste encore incertain. Il pourrait être très différent selon que la RCP soit considérée dans les arrêts cardiaques extrahospitaliers ou intrahospitaliers, d’origine cardiaque ou pas, en contexte toxicologique ou d’hypothermie. L’objectif de cet article est une mise au point sur l’apport de l’assistance circulatoire extracorporelle dans la prise en charge des arrêts cardiaques réfractaires à partir des recherches cliniques les plus récentes. Ainsi, l’apport d’une RCP extracorporelle dans les arrêts cardiaques réfractaires extrahospitaliers d’origine cardiaque est probablement limité, même au sein de populations hautement sélectionnées. En revanche, son intérêt est probablement plus important dans les arrêts cardiaques réfractaires intrahospitaliers d’origine cardiaque sous réserve d’une bonne sélection des patients. Enfin, si des résultats encourageants ont été rapportés dans les cas d’arrêt cardiaque réfractaire de cause toxique ; en revanche, ils sont plus contrastés concernant les arrêts cardiaques réfractaires associés à une hypothermie profonde suite à une exposition accidentelle au froid, à une noyade ou une avalanche. Des recherches bien conduites sont encore nécessaires pour préciser les contextes et les indications pour lesquels les patients seraient en droit d’attendre un bénéfice médical d’une RCP extracorporelle.

Place de l’assistance circulatoire extracorporelle dans l’arrêt cardiaque réfractaire

Le bénéfice d’une réanimation cardiopulmonaire (RCP) extracorporelle en comparaison d’une réanimation conventionnelle sur la survie et le pronostic neurologique à long terme des patients victimes d’un arrêt cardiaque réfractaire reste encore incertain. Il pourrait être très différent selon que la RCP soit considérée dans les arrêts cardiaques extrahospitaliers ou intrahospitaliers, d’origine cardiaque ou pas, en contexte toxicologique ou d’hypothermie. L’objectif de cet article est une mise au point sur l’apport de l’assistance circulatoire extracorporelle dans la prise en charge des arrêts cardiaques réfractaires à partir des recherches cliniques les plus récentes. Ainsi, l’apport d’une RCP extracorporelle dans les arrêts cardiaques réfractaires extrahospitaliers d’origine cardiaque est probablement limité, même au sein de populations hautement sélectionnées. En revanche, son intérêt est probablement plus important dans les arrêts cardiaques réfractaires intrahospitaliers d’origine cardiaque sous réserve d’une bonne sélection des patients. Enfin, si des résultats encourageants ont été rapportés dans les cas d’arrêt cardiaque réfractaire de cause toxique ; en revanche, ils sont plus contrastés concernant les arrêts cardiaques réfractaires associés à une hypothermie profonde suite à une exposition accidentelle au froid, à une noyade ou à une avalanche. Des recherches bien conduites sont encore nécessaires pour préciser les contextes et les indications pour lesquels les patients seraient en droit d’attendre un bénéfice médical d’une RCP extracorporelle.

Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study

PURPOSE

To compare the efficacy of an antibiotic protocol guided by serum procalcitonin (PCT) with that of standard antibiotic therapy in severe acute exacerbations of COPD (AECOPDs) admitted to the intensive care unit (ICU).

METHODS

We conducted a multicenter, randomized trial in France. Patients experiencing severe AECOPDs were assigned to groups whose antibiotic therapy was guided by (1) a 5-day PCT algorithm with predefined cutoff values for the initiation or stoppage of antibiotics (PCT group) or (2) standard guidelines (control group). The primary endpoint was 3-month mortality. The predefined noninferiority margin was 12%.

RESULTS

A total of 302 patients were randomized into the PCT (n = 151) and control (n = 151) groups. Thirty patients (20%) in the PCT group and 21 patients (14%) in the control group died within 3 months of admission (adjusted difference, 6.6%; 90% CI - 0.3 to 13.5%). Among patients without antibiotic therapy at baseline (n = 119), the use of PCT significantly increased 3-month mortality [19/61 (31%) vs. 7/58 (12%), p = 0.015]. The in-ICU and in-hospital antibiotic exposure durations, were similar between the PCT and control group (5.2 ± 6.5 days in the PCT group vs. 5.4 ± 4.4 days in the control group, p = 0.85 and 7.9 ± 8 days in the PCT group vs. 7.7 ± 5.7 days in the control group, p = 0.75, respectively).

CONCLUSION

The PCT group failed to demonstrate non-inferiority with respect to 3-month mortality and failed to reduce in-ICU and in-hospital antibiotic exposure in AECOPDs admitted to the ICU.

Predicting Survival After Extracorporeal Membrane Oxygenation for ARDS: An External Validation of RESP and PRESERVE Scores

BACKGROUND

We aimed to test the performance of PRESERVE and RESP scores to predict death in patients with severe ARDS receiving extracorporeal membrane oxygenation (ECMO) with different case mixes.

METHODS

All consecutive patients treated with ECMO for refractory ARDS, regardless of cause, in the Caen University Hospital in northwestern France over the last decade were included in a retrospective cohort study. The receiver operating characteristic curves of each score were plotted, and the area under the curve was computed to assess their performance in predicting mortality (c-index).

RESULTS

Forty-one subjects were included. Pre-ECMO ventilator settings were: mean V_T, 6.1 ± 0.9 mL/kg; breathing frequency, 32 ± 4 breaths/min; PEEP, 11 ± 4 cm H₂O; peak inspiratory pressure, 48 ± 9 cm H₂O; plateau pressure, 30.4 ± 4.4 cm H₂O. At ECMO initiation, blood gas results were: pH 7.22 ± 0.17, P_aO2 /F_IO2 = 63 ± 22 mm Hg; P_aCO2 = 56 ± 18 mm Hg; F_IO2 = 99 ± 2%. Pre-ECMO data were available in 35 and 27 subjects for calculation of the PRESERVE score and RESP score, respectively. Pre-ECMO scoring system results were: median PRESERVE score, 4 (interquartile range 2-5), and median RESP score, 0 (interquartile range -2 to 2). Twenty-three subjects (56%) died, including 19 receiving ECMO. In univariate analysis, plateau pressure (P = .031), driving pressure (P = <.001), and compliance (P = .02) recorded at the time of ECMO initiation as well as the PRESERVE score (P = .032) were significantly associated with mortality. With a c-index of 0.69 (95% CI 0.53-0.87), the PRESERVE score had better discrimination than the RESP score (c-index of 0.60 [95% CI 0.41-0.78]) for predicting mortality.

CONCLUSIONS

The use of these scores in helping physicians to determine the patients with ARDS most likely to benefit from ECMO should be limited in clinical practice because of their relatively poor performance in predicting death in subjects with severe ARDS receiving ECMO support. Before widespread use is initiated, these scoring systems should be tested in large prospective studies of subjects with severe ARDS undergoing ECMO treatment.

Impact of a Paper-Based Dynamic Insulin Infusion Protocol on Glycemic Variability, Time in Target, and Hypoglycemic Risk: A Stepped Wedge Trial in Medical Intensive Care Unit Patients

BACKGROUND

Stress-induced hyperglycemia is a common feature of intensive care unit (ICU) patients. Besides mean blood glucose (BG) level, glucose variability and hypoglycemia have been highlighted as independent predictors of ICU and hospital mortality. Recent ICU recommendations suggest using insulin infusion protocols that can minimize glucose variability and hypoglycemic risk. Our aim was to assess the efficacy, safety, and acceptance by nurses of a paper-based simple dynamic insulin protocol compared with those by nurses of a paper-based static protocol.

METHODS

This is a 1 year stepped-wedge study that compared a static sliding scale protocol (SP - static protocol) with a validated dynamic paper-based intravenous insulin infusion protocol (DP - dynamic protocol) in medical ICU patients of a single university hospital. Patients with stress-induced hyperglycemia >9.9 mmol/L and ≥48 h intravenous insulin infusion were included in this trial.

RESULTS

One hundred thirty-one patients were included and received continuous intravenous insulin infusion managed with SP (n = 65) or DP (n = 66). Glucose variability was significantly higher in the SP group than in the DP group (mean average glucose excursion index: 0.90 [0.00-1.91] mmol/L vs. 0.00 [0.00-0.90] mmol/L, respectively; P = 0.001). The percentage of time spent in the target range (7.7-9.9 mmol/L) was lower in the SP group than in the DP group (42.5% [28.8%-54.2%] vs. 47.5% [36.6%-57.1%]; P = 0.037). Low BG (<4.4 mmol/L) and hypoglycemia (<3.3 mmol/L) were more frequent in the SP group than in the DP group. According to a satisfaction survey, this protocol was well accepted by nurses.

CONCLUSIONS

Our simple and feasible paper-based, dynamic insulin infusion protocol reduced glycemic variability and hypoglycemic risk in a medical ICU.

Immature/total granulocyte ratio improves early prediction of neurological outcome after out-of-hospital cardiac arrest: the MyeloScore study

Background

Elevation of the immature/total granulocyte (I/T-G) ratio has been reported after out-of-hospital cardiac arrest (OHCA). Our purpose here was to evaluate the prognostic significance of the I/T-G ratio and to investigate whether the I/T-G ratio improves neurological outcome prediction after OHCA.

Methods

This single-center prospective cohort study included consecutive immunocompetent patients admitted to our intensive care unit over a 3-year period (2012–2014) after successfully resuscitated OHCA. The I/T-G ratio was determined in blood samples collected at admission.

Results

We studied 204 patients (77 % male, median age, 58 [48–67] years), of whom 64 % had a suspected cardiac cause of OHCA, 62 % died in the unit, and 31.5 % survived with good cerebral function. Independent outcome predictors by multivariate analysis were age, first shockable rhythm, bystander-initiated resuscitation, and I/T-G ratio. Compared to the model computed without the I/T-G ratio, the model with the ratio performed significantly better [areas under the ROC curves (AUCs), 0.78 vs. 0.83, respectively; P = 0.04]. These items were used to develop the MyeloScore equation: ([0.47 × I/T-G ratio] + [0.023 × age in years]) − 1.26 if initial VF/VT − 1.1 if bystander-initiated CPR. The MyeloScore predicted neurological outcomes with similar accuracy to the previously reported OHCA score (0.83 and 0.85, respectively; P = 0.6). The ROC–AUC was 0.84, providing external validation of the MyeloScore.

Conclusions

The I/T-G ratio independently predicts neurological outcome after OHCA and, when added to other known risk factors, improves neurological outcome prediction. The clinical performance of the MyeloScore requires evaluation in a prospective study.

Comparison of alcoholic chlorhexidine and povidone-iodine cutaneous antiseptics for the prevention of central venous catheter-related infection: a cohort and quasi-experimental multicenter study

PURPOSE

Compare the effectiveness of different cutaneous antiseptics in reducing risk of catheter-related infection in intensive care unit (ICU) patients.

METHODS

We compared the risk of central venous catheter-related infection according to four-step (scrub, rinse, dry, and disinfect) alcoholic 5 % povidone-iodine (PVI-a, n = 1521), one-step (disinfect) alcoholic 2 % chlorhexidine (2 % CHX-a, n = 1116), four-step alcoholic <1 % chlorhexidine (<1 % CHX-a, n = 357), and four-step aqueous 10 % povidone-iodine (PVI, n = 368) antiseptics used for cutaneous disinfection and catheter care during the 3SITES multicenter randomized controlled trial. Within this cohort, we performed a quasi-experimental study (i.e., before-after) involving the four ICUs which switched from PVI-a to 2 % CHX-a. We used propensity score matching (PSM, n = 776) and inverse probability weighting treatment (IPWT, n = 1592). The end point was the incidence of catheter-related infection (CRI) defined as catheter-related bloodstream infection (CRBSI) or a positive catheter tip culture plus clinical sepsis on catheter removal.

RESULTS

In the cohort analysis and compared with PVI-a, the incidence of CRI was lower with 2 % CHX-a [adjusted hazard ratio (aHR), 0.51; 95 % confidence interval (CI) (0.28-0.96), p = 0.037] and similar with <1 % CHX-a [aHR, 0.73; (0.36-1.48), p = 0.37] and PVI [aHR, 1.50; 95 % CI (0.85-2.64), p = 0.16] after controlling for potential confounders. In the quasi-experimental study and compared with PVI-a, the incidence of catheter-related infection was again lower with 2 % CHX-a after PSM [HR, 0.35; 95 % CI (0.15, 0.84), p = 0.02] and in the IPWT analysis [HR, 0.31; 95 % CI (0.14, 0.70), p = 0.005]. The incidence of CRBSI or adverse event was not significantly different between antiseptics in all analyses.

CONCLUSIONS

In comparison with PVI-a, the use of 2 % CHX-a for cutaneous disinfection of the central venous catheter insertion site and maintenance catheter care was associated with a reduced risk of catheter infection, while the benefit of <1 % CHX-a was uncertain.

CLINICAL TRIALS IDENTIFIER

NCT01479153.

Diagnostic accuracy of hemoconcentration for pulmonary edema as the cause of weaning failure

BACKGROUND

Our objective was to assess the diagnostic accuracy of hemoconcentration for cardiogenic pulmonary edema (PE) as the cause of weaning failure, using left ventricular filling pressure elevation assessed by transthoracic echocardiography as the reference standard.

METHODS

This prospective observational study included 41 patients who failed their first spontaneous breathing trial of weaning from mechanical ventilation. They were divided into two groups, with and without PE by echocardiographic criteria. Hemoconcentration and other hemodynamic parameters were compared between the groups.

RESULTS

The group (N.=21) with PE by echocardiographic criteria had a higher frequency of failure of the second spontaneous breathing trial (P=0.03) and a longer total weaning time (P=0.02) compared to the other group. The receiver-operating characteristics curve indicated that changes in plasma protein or hemoglobin concentration from initiation to completion of the second spontaneous breathing trial did not predict PE as the cause of failure (areas under the receiver-operating characteristics curve, 0.47±0.09 and 0.51±0.09, respectively). The only factor predicting failure due to PE was a positive fluid balance from intensive care unit admission to study inclusion (P=0.01). The increase in mean arterial blood pressure seemed suggestive of weaning failure due to cardiac causes.

CONCLUSIONS

Compared to echocardiographic criteria for left ventricular filling pressure elevation, hemoconcentration assessed based on plasma protein and hemoglobin levels did not help to diagnose cardiogenic PE as the cause of weaning failure.

Intravascular Complications of Central Venous Catheterization by Insertion Site

BACKGROUND

Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for major complications.

METHODS

In this multicenter trial, we randomly assigned nontunneled central venous catheterization in patients in the adult intensive care unit (ICU) to the subclavian, jugular, or femoral vein (in a 1:1:1 ratio if all three insertion sites were suitable [three-choice scheme] and in a 1:1 ratio if two sites were suitable [two-choice scheme]). The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis.

RESULTS

A total of 3471 catheters were inserted in 3027 patients. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group (hazard ratio, 3.5; 95% confidence interval [CI], 1.5 to 7.8; P=0.003) and in the jugular group than in the subclavian group (hazard ratio, 2.1; 95% CI, 1.0 to 4.3; P=0.04), whereas the risk in the femoral group was similar to that in the jugular group (hazard ratio, 1.3; 95% CI, 0.8 to 2.1; P=0.30). In the three-choice comparison, pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions.

CONCLUSIONS

In this trial, subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular-vein or femoral-vein catheterization. (Funded by the Hospital Program for Clinical Research, French Ministry of Health; ClinicalTrials.gov number, NCT01479153.).

Use of online blood volume and blood temperature monitoring during haemodialysis in critically ill patients with acute kidney injury: a single-centre randomized controlled trial

BACKGROUND

Little is known about the clinical impact on cardiovascular stability during intermittent haemodialysis (IHD) for acute kidney injury (AKI) of online monitoring devices that control blood volume (BV) and blood temperature in the intensive care unit (ICU) setting. We compared different dialysis treatment modalities with or without these new systems among critically ill patients requiring IHD.

METHODS

In a prospective single-centre three-arm randomized controlled trial, 600 dialysis sessions in 74 consecutive AKI critically ill patients were involved to assess intradialytic hypotension. Standard dialysis therapy with constant ultrafiltration (UF) rate, cool dialysate and high sodium conductivity (Treatment A) was compared to regimens with adjunctive interventions including BV control (Treatment B) and the combination of BV and active blood temperature control (Treatment C). Each dialysis session was randomly assigned to one of the three treatment arms and served as statistical unit.

RESULTS

Five hundred and seventy-two dialysis sessions were analysed (188, 190 and 194 in Treatments A, B and C, respectively). Hypotension occurred in 16.6% treatments, with similar rates among the arms. Haemodynamic parameters and dialysis-related complications did not differ between therapies. Based on generalized estimating equation adjusted to dialysate sodium conductivity, higher Sequential Organ Failure Assessment the day of dialysis session, the need for vasopressors and lower systolic blood pressure at the onset of the session were identified as independent predictors of hypotensive episodes, whereas regimens containing the new online monitors were not.

CONCLUSIONS

These results suggest that both actively controlled body temperature and UF profiled by online monitoring systems have no significant impact on the incidence of intradialytic hypotension in the ICU setting. Further research is needed before the use of these new sophisticated automatic methods can be applied routinely to the ICU setting.

Incidence, morbidity, and mortality of contrast-induced acute kidney injury in a surgical intensive care unit: a prospective cohort study

PURPOSE

Data on contrast-induced acute kidney injury (CI-AKI) in intensive care unit (ICU) are scarce and controversial. The objectives of the study were to evaluate the incidence and characteristics of CI-AKI in a surgical ICU.

MATERIALS AND METHODS

We conducted a 13-month prospective observational study. Three definitions were compared to characterize CI-AKI: Barrett and Parfrey criteria; Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function and End stage renal disease (RIFLE) classification; and Acute Kidney Injury Network (AKIN) criteria. Patients hospitalized in surgical ICU who had received an injection of contrast medium, who were not on renal replacement therapy, who had stable serum creatinine before injection, and no other etiology for new acute kidney injury were included.

RESULTS

One hundred one patients were included. The frequency of CI-AKI was 17%, 19%, and 19% according to Barrett and Parfrey criteria; RIFLE classification; and AKIN criteria, respectively. Diabetes mellitus, creatinine clearance less than 60 mL/min, and concomitant aminoglycoside administration were associated with CI-AKI. Statistically significant associations were found between CI-AKI and renal replacement therapy with all 3 definitions and between CI-AKI and mortality when AKIN criteria were used.

CONCLUSIONS

These results show that CI-AKI is not inconsequential in critically ill patients. In the present study, AKIN criteria appear to be most relevant to define CI-AKI. Further studies are required to explore CI-AKI prevention in ICU.

Serum neuron-specific enolase as predictor of outcome in comatose cardiac-arrest survivors: a prospective cohort study

BACKGROUND

The prediction of neurological outcome in comatose patients after cardiac arrest has major ethical and socioeconomic implications. The purpose of this study was to assess the capability of serum neuron-specific enolase (NSE), a biomarker of hypoxic brain damage, to predict death or vegetative state in comatose cardiac-arrest survivors.

METHODS

We conducted a prospective observational cohort study in one university hospital and one general hospital Intensive Care Unit (ICU). All consecutive patients who suffered cardiac arrest and were subsequently admitted from June 2007 to February 2009 were considered for inclusion in the study. Patients who died or awoke within the first 48 hours of admission were excluded from the analysis. Patients were followed for 3 months or until death after cardiopulmonary resuscitation. The Cerebral Performance Categories scale (CPC) was used as the outcome measure; a CPC of 4-5 was regarded as a poor outcome, and a CPC of 1-3 a good outcome. Measurement of serum NSE was performed at 24 h and at 72 h after the time of cardiac arrest using an enzyme immunoassay. Clinicians were blinded to NSE results.

RESULTS

Ninety-seven patients were included. All patients were actively supported during the first days following cardiac arrest. Sixty-five patients (67%) underwent cooling after resuscitation. At 3 months 72 (74%) patients had a poor outcome (CPC 4-5) and 25 (26%) a good outcome (CPC 1-3). The median and Interquartile Range [IQR] levels of NSE at 24 h and at 72 h were significantly higher in patients with poor outcomes: NSE at 24 h: 59.4 ng/mL [37-106] versus 28.8 ng/mL [18-41] (p < 0.0001); and NSE at 72 h: 129.5 ng/mL [40-247] versus 15.7 ng/mL [12-19] (p < 0.0001). The Receiver Operator Characteristics (ROC) curve for poor outcome for the highest observed NSE value for each patient determined a cut-off value for NSE of 97 ng/mL to predict a poor neurological outcome with a specificity of 100% [95% CI = 87-100] and a sensitivity of 49% [95% CI = 37-60]. However, an approach based on a combination of SSEPs, NSE and clinical-EEG tests allowed to increase the number of patients (63/72 (88%)) identified as having a poor outcome and for whom intensive treatment could be regarded as futile.

CONCLUSION

NSE levels measured early in the course of patient care for those who remained comatose after cardiac arrest were significantly higher in patients with outcomes of death or vegetative state. In addition, we provide a cut-off value for NSE (> 97 ng/mL) with 100% positive predictive value of poor outcome. Nevertheless, for decisions concerning the continuation of treatment in this setting, we emphasize that an approach based on a combination of SSEPs, NSE and clinical EEG would be more accurate for identifying patients with a poor neurological outcome.

Predictors of mortality and short-term physical and cognitive dependence in critically ill persons 75 years and older: a prospective cohort study

BACKGROUND

The purpose of this study was to identify predictors of 3-month mortality in critically ill older persons under medical care and to assess the clinical impact of an ICU stay on physical and cognitive dependence and subjective health status in survivors.

METHODS

We conducted a prospective observational cohort study including all older persons 75 years and older consecutively admitted into ICU during a one-year period, except those admitted after cardiac arrest, All patients were followed for 3 months or until death. Comorbidities were assessed using the Charlson index and physical dependence was evaluated using the Katz index of Activity of Daily Living (ADL). Cognitive dependence was determined by a score based on the individual components of the Lawton index of Daily Living and subjective health status was evaluated using the Nottingham Health Profile (NHP) score.

RESULTS

One hundred patients were included in the analysis. The mean age was 79.3 ± 3.4 years. The median Charlson index was 6 [IQR, 4 to 7] and the mean ADL and cognitive scores were 5.4 ± 1.1 and 1.2 ± 1.4, respectively, corresponding to a population with a high level of comorbidities but low physical and cognitive dependence. Mortality was 61/100 (61%) at 3 months. In multivariate analysis only comorbidities assessed by the Charlson index [Adjusted Odds Ratio, 1.6; 95% CI, 1.2-2.2; p < 0.003] and the number of organ failures assessed by the SOFA score [Adjusted Odds Ratio, 2.5; 95% CI, 1.1-5.2; p < 0.02] were independently associated with 3-month mortality. All 22 patients needing renal support after Day 3 died. Compared with pre-admission, physical (p = 0.04), and cognitive (p = 0.62) dependence in survivors had changed very little at 3 months. In addition, the mean NHP score was 213.1 ± 132.8 at 3 months, suggesting an acceptable perception of their quality of life.

CONCLUSIONS

In a selected population of non surgical patients 75 years and older, admission into the ICU is associated with a 3-month survival rate of 38% with little impact on physical and cognitive dependence and subjective health status. Nevertheless, a high comorbidity level (ie, Charlson index), multi-organ failure, and the need for extra-renal support at the early phase of intensive care could be considered as predictors of death.