Risk factors for difficult ventilatory weaning in intensive care patients with cervical cellulitis

PURPOSE

Cervical cellulitis is an infrequent but serious infection. The management of the upper airways is difficult, at the actual time of intubation but also regarding the necessity of maintaining mechanical ventilation. The objective of this study is to identify risk factors on admission to the intensive care unit for difficult ventilatory weaning in patients with cervical cellulitis.

METHODS

Between January 2013 and December 2018, this retrospective observational study was performed in an intensive care unit with 10 beds in a university hospital recognized as a reference center for the management of cellulitis. All intensive care patients receiving mechanical ventilation after surgery for cervical cellulitis were eligible. Difficult ventilatory weaning was defined as mechanical ventilation lasting more than 7 days or failure of extubation as established by the WIND 2017 study.

RESULTS

We included 120 patients with severe cervical cellulitis. The median age was 43 years. Eighteen patients (16%) presented mediastinal extension. The risk factor for difficult ventilatory weaning (n = 49) in multivariate analysis was a high level of procalcitonin on admission (OR at 1.14[1.005-1.29]; p<0.042) and the protective factor was surgery in an expert center (OR at 0.11[0.026-0.47]; p<0.003). Eight patients required a tracheotomy in our study: 3 patients during surgery and at a later time for the other 5 of our 8 patients.

CONCLUSION

No intensive care studies have investigated ventilatory weaning risk factors in patients with cervical cellulitis. Yet simple criteria seem to predict this risk. It is now necessary to confirm them by a multicenter prospective study.

Venoarterial Extracorporeal Membrane Oxygenation in Severe Drug Intoxication: A Retrospective Comparison of Survivors and Nonsurvivors

Selecting patients most likely to benefit from venoarterial extracorporeal membrane oxygenation (V-A ECMO) to treat refractory drug-induced cardiovascular shock remains a difficult challenge for physicians. This study reported short-term survival outcomes and factors associated with mortality in V-A ECMO-treated patients for poisoning. Twenty-two patients placed on V-A ECMO after drug intoxication from January 2014 to December 2020 were retrospectively analyzed. The primary endpoint of this study was survival at hospital discharge. Univariate descriptive analysis was performed to compare survivors and nonsurvivors during hospitalization. The overall survival at hospital discharge was 45.4% (n = 10/22). Survival rate tended to be higher in patients treated for refractory shock (n = 7/10) compared with those treated for refractory cardiac arrest (n = 3/12, p = 0.08). Low-flow duration and time from admission to ECMO cannulation were shorter in survivors ( p = 0.02 and p = 0.03, respectively). Baseline characteristics before ECMO, including the class of drugs involved in the poisoning, between survivors and nonsurvivors were not statistically different except pH, bicarbonate, serum lactate, Sequential Organ Failure Assessment, and Survival After Veno-arterial-ECMO (SAVE) score. All patients with SAVE-score risk classes II/III survived whereas 85.7% (n = 12/14) of those with SAVE-score risk classes IV/V died. A lactic acid >9 mmol/L predicts mortality with a sensitivity/specificity ratio of 83.3%/100%. V-A ECMO for severe drug intoxication should be reserved for highly selected poisoned patients who do not respond to conventional therapies. Shortening the timing of V-A ECMO initiation should be a key priority in improving outcomes. Low-flow time >60min, lactic acid >9mmol/L, and SAVE-score may be good indicators of a worse prognosis.

Extracorporeal Membrane Oxygenation for COVID 2019-Acute Respiratory Distress Syndrome: Comparison between First and Second Waves (Stage 2)

We aimed to compare the outcomes of patients under veno-venous extracorporeal membrane oxygenation (V-V ECMO) for COVID-19-Acute Respiratory Distress Syndrome (CARDS) between the first and the second wave. From 1 March 2020 to 30 November 2020, fifty patients requiring a V-V ECMO support for CARDS were included. Patient demographics, pre-ECMO, and day one, three, and seven on-ECMO data and outcomes were collected. The 90-day mortality was 11% higher during the second wave (18/26 (69%)) compared to the first wave (14/24 (58%) (p = 0.423). During the second wave, all of the patients were given steroids compared to 16.7% during the first wave (p < 0.001). The second wave's patients had been on non-invasive ventilation support for a longer period than in the first wave, with the median time from ICU admission to ECMO implantation being significantly higher (14 (11-20) vs. 7.7 (5-12) days; p < 0.001). Mechanical properties of the lung were worsened in the second wave's CARDS patients before ECMO implantation (median static compliance 20 (16-26) vs. 29 (25-37) mL/cmH2O; p < 0.001) and during ECMO days one, three, and seven. More bacterial co-infections before implantation and under ECMO were documented in the second wave group. Despite a better evidence-driven critical care management, we depicted fewer encouraging outcomes during the second wave.

Hyperbaric hyperoxemia as a risk factor for ventilator-acquired pneumonia?

OBJECTIVES

Ventilator-acquired pneumonia (VAP) is the leading cause of serious associated infections in Intensive Care Units (ICU) and is associated with significant morbidity. The use of hyperbaric oxygen therapy (HBOT) in patients on mechanical ventilation may increase exposure to certain risk factors such as hyperoxemia and the need for multiple transfers. The aim of our study was to assess the relationship between HBOT and VAP.

METHOD

This retrospective observational study was performed from March 2017 to March 2018 in a 10-bed ICU using HBOT. All patients receiving mechanical ventilation (MV) for more than 48 hours were eligible. VAP was defined using clinical and radiological criteria. Data collection was carried out via digital medical records. Risk factors for VAP were determined by univariate and multivariate analysis.

RESULTS

Forty-two (23%) of the 182 patients enrolled developed at least one episode of VAP. One hundred and twenty-four (68%) patients received HBOT. The incidence rate of VAP was 34 per 1000 ventilator days. The occurrence of VAP was significantly associated with immunosuppression (p<0.029), MV duration (5 [3-7] vs 8 [5-11.5] days, p<0.0001), length of stay (8 [5-13] vs 19.5 [13-32] days, p<0.0001), reintubation (p<0.0001), intra-hospital transport (p = 0.001), use of paralytic agents (p = 0.013), tracheotomy (p = 0.003) and prone position (p = 0.003). The use of HBOT was not associated with the occurrence of VAP. Multivariate analysis identified reintubation (OR: 8.3 [2.6-26.6]; p<0.0001), intra-hospital transport (OR: 3.5 [1.3-9.2]; p = 0.011) and the use of paralytic agents (OR: 3.3 [1.3-8.4]; p = 0.014) as independent risk factors for VAP.

CONCLUSION

Known risk factors for VAP are to be found within our ICU population. HBOT, however, is not an extra risk factor for VAP within this group. Further experimental and clinical investigations are needed to understand the impact of HBOT on the occurrence of VAP and on physiological microbiome.

Treating ARDS-associated air embolism: a question of priorities

Gas embolism is a potential and often life-threatening complication of central venous catheters. We report a case of air embolism after tearing of the central catheter associated with severe acute respiratory distress syndrome. The severity of the clinical situation meant choices had to be made regarding the order of treatments. This clinical case provided useful eye-openers for patient management regarding the prioritization of treatments as well as the possibilities offered by hyperbaric oxygen therapy.

Evaluation of pressure in water-filled endotracheal tube cuffs in intubated patients undergoing hyperbaric oxygen treatment

INTRODUCTION

Inflating endotracheal tube cuffs using water instead of air before hyperbaric oxygen treatment (HBOT) is common. The objective of this study was to assess cuff pressure (P_cuff), when the cuff was inflated using water, in normobaric conditions and during HBOT.

METHODS

This was a prospective, observational study taking place in hyperbaric centre and intensive care unit of the University Hospital of Lille. Every patient who required tracheal intubation and HBOT at 253.3 kPa (2.5 atmospheres absolute [atm abs]) was included. P_cuff was measured using a pressure transductor connected to the cuff inflating port. Measurements were performed at 'normobaria' (1 atm abs) and during HBOT at 2.5 atm abs.

RESULTS

Thirty patients were included between February and April 2016. Recordings were analysable in 27 patients. Mean P_cuff at normobaria was 60.8 (SD 42) cmH₂O. Nineteen (70%) of patients had an excessive P_cuff (higher than 30 cmH₂O). Coefficient of variation was 69%. Mean P_cuff at 2.5 atm abs was 51.6 (40.7) cmH₂O, significantly lower than at normobaria (P < 0.0001). Coefficient of variation was 79%. In only five (18%) patients was P_cuff < 20 cmH₂O at 2.5 atm abs.

CONCLUSIONS

In normobaric conditions, when the cuff was inflated using water and not specifically controlled P_cuff was not predictable. The cuff was typically over-inflated exceeding safe pressure. During HBOT P_cuff decreased slightly.

Place de l'oxygénothérapie hyperbare en 2019

L’oxygénothérapie hyperbare (OHB) est une modalité thérapeutique par laquelle de l’oxygène (O2) est administré parvoie respiratoire à un patient installé dans une chambre où la pression est supérieure à la pression atmosphérique. Lesbénéfi ces thérapeutiques de l’OHB résultent des effets physiques liés à l’augmentation de la pression barométrique(réduction de volume des amas gazeux) et de la pression partielle en O2 dans les tissus (augmentation du transportet de la délivrance tissulaire en oxygène et effets propres de l’hyperoxie tissulaire). Réaliser des séances d’OHB enurgence et/ou pour des patients de réanimation nécessite une organisation, un plateau technique adapté et une maîtrisede ces prises en charge par tous les intervenants du centre hyperbare. C’est une technique complexe, qui nécessite uninvestissement humain et matériel. Elle comporte quelques contre-indications à respecter et des risques bien identifi ésà prendre en compte. Le rapport bénéfi ce-risque doit être systématiquement évalué en fonction de l’état du patient,du caractère d’urgence, de l’accessibilité au centre hyperbare et de la proximité d’un service de réanimation. Sesindications sont régulièrement évaluées dans le cadre de conférences de consensus internationales dont la dernière,européenne, s’est tenue à Lille en 2016.

Effect of an ICU Diary on Posttraumatic Stress Disorder Symptoms Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial

IMPORTANCE

Keeping a diary for patients while they are in the intensive care unit (ICU) might reduce their posttraumatic stress disorder (PTSD) symptoms.

OBJECTIVES

To assess the effect of an ICU diary on the psychological consequences of an ICU hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

Assessor-blinded, multicenter, randomized clinical trial in 35 French ICUs from October 2015 to January 2017, with follow-up until July 2017. Among 2631 approached patients, 709 adult patients (with 1 family member each) who received mechanical ventilation within 48 hours after ICU admission for at least 2 days were eligible, 657 were randomized, and 339 were assessed 3 months after ICU discharge.

INTERVENTIONS

Patients in the intervention group (n = 355) had an ICU diary filled in by clinicians and family members. Patients in the control group (n = 354) had usual ICU care without an ICU diary.

MAIN OUTCOMES AND MEASURES

The primary outcome was significant PTSD symptoms, defined as an Impact Event Scale-Revised (IES-R) score greater than 22 (range, 0-88; a higher score indicates more severe symptoms), measured in patients 3 months after ICU discharge. Secondary outcomes, also measured at 3 months and compared between groups, included significant PTSD symptoms in family members; significant anxiety and depression symptoms in patients and family members, based on a Hospital Anxiety and Depression Scale score greater than 8 for each subscale (range, 0-42; higher scores indicate more severe symptoms; minimal clinically important difference, 2.5); and patient memories of the ICU stay, reported with the ICU memory tool.

RESULTS

Among 657 patients who were randomized (median [interquartile range] age, 62 [51-70] years; 126 women [37.2%]), 339 (51.6%) completed the trial. At 3 months, significant PTSD symptoms were reported by 49 of 164 patients (29.9%) in the intervention group vs 60 of 175 (34.3%) in the control group (risk difference, -4% [95% CI, -15% to 6%]; P = .39). The median (interquartile range) IES-R score was 12 (5-25) in the intervention group vs 13 (6-27) in the control group (difference, -1.47 [95% CI, -1.93 to 4.87]; P = .38). There were no significant differences in any of the 6 prespecified comparative secondary outcomes.

CONCLUSIONS AND RELEVANCE

Among patients who received mechanical ventilation in the ICU, the use of an ICU diary filled in by clinicians and family members did not significantly reduce the number of patients who reported significant PTSD symptoms at 3 months. These findings do not support the use of ICU diaries for preventing PTSD symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02519725.

[Carbon monoxide poisoning]

Carbon monoxide poisoning. Carbon monoxide poisoning is a frequent and serious intoxication with an important pre-hospital mortality. The diagnosis is made by the association of a context and compatible neurological and cardiac clinical signs. This diagnosis is now eased by home or firefighters detectors. Management is based primarily on the extraction of the toxic atmosphere and the administration of oxygen in emergency and, according to clinical presentation or context, hyperbaric oxygen therapy. This specialized therapy is necessary when exist any objective clinical sign, loss of consciousness or pregnancy. It aims to reduce the risk of neuropsychological and cognitive sequelae. Prevention of this intoxication is essential and motivates its reporting to the regional health agency.

Impact of subglottic secretion drainage on microaspiration in critically ill patients: a prospective observational study

Background

Microaspiration is a major factor in ventilator-associated pneumonia (VAP) pathophysiology. Subglottic secretion drainage (SSD) aims at reducing its incidence.

Methods

Single-center prospective observational study, performed in a French intensive care unit (ICU) from March 2012 to April 2013, including adult patients mechanically ventilated for at least 24 hours divided in two groups: patients in the SSD group intubated using tracheal tubes allowing SSD and patients in the control group intubated with standard tracheal tubes. Pepsin and salivary amylase concentrations were measured for 24 hours in all tracheal aspirates. Primary objective was to determine the impact of SSD on gastric or oropharyngeal microaspiration using pepsin or amylase concentration in tracheal aspirates.

Results

Fifty-five patients were included in the SSD group and 45 in the control group. No difference was found between groups regarding the incidence of microaspiration defined as at least one tracheal aspirate positive for either pepsin or amylase [49 (89%) vs. 37 (82%), P=0.469]. Percentage of patients with VAP [16 (29%) vs. 11 (24%), P=0.656], ventilator-associated tracheobronchitis (VAT) [7 (13%) vs. 4 (9%), P=0.750] or early airway colonization [15 (35%) vs. 8 (18%), P=0.219] were not significantly different in study groups.

Conclusions

SSD did not reduce the incidence of microaspiration, VAP, VAT or airway colonization in this observational study.

Sodium lactate improves renal microvascular thrombosis compared to sodium bicarbonate and 0.9% NaCl in a porcine model of endotoxic shock: an experimental randomized open label controlled study

Background

Sodium lactate seemed to improve fluid balance and avoid fluid overload. The objective of this study was to determine if these beneficial effects can be at least partly explained by an improvement in disseminated intravascular coagulation (DIC)-associated renal microvascular thrombosis.

Methods

Ancillary work of an interventional randomized open label controlled experimental study. Fifteen female “Large White” pigs (2 months old) were challenged with intravenous infusion of E. coli endotoxin. Three groups of five animals were randomly assigned to receive different fluids: a treatment group received sodium lactate 11.2% (SL group); an isotonic control group received 0.9% NaCl (NC group); a hypertonic control group, with the same amount of osmoles and sodium than SL group, received sodium bicarbonate 8.4% (SB group). Glomerular filtration rate (GFR) markers, coagulation and inflammation parameters were measured over a 5-h period. Immediately after euthanasia, kidneys were withdrawn for histological study. Statistical analysis was performed with nonparametric tests and the Dunn correction for multiple comparisons. A p < 0.05 was considered significant.

Results

The direct immunofluorescence study revealed that the percentage of capillary sections thrombosed in glomerulus were significantly lesser in SL group [5 (0–28) %] compared to NC [64 (43–79) %, p = 0.01] and SB [64 (43–79), p = 0.03] groups. Alterations in platelet count and fibrinogen level occurred earlier and were significantly more pronounced in both control groups compared to SL group (p < 0.05 at 210 and 300 min). The increase in thrombin–antithrombin complexes was significantly higher in NC [754 (367–945) μg/mL; p = 0.03] and SB [463 (249–592) μg/mL; p = 0.03] groups than in SL group [176 (37–265) μg/mL]. At the end of the experiment, creatinine clearance was significantly higher in SL group [55.46 (30.07–67.85) mL/min] compared to NC group [1.52 (0.17–27.67) mL/min, p = 0.03].

Conclusions

In this study, we report that sodium lactate improves DIC-associated renal microvascular thrombosis and preserves GFR. These findings could at least partly explain the better fluid balance observed with sodium lactate infusion.

The ICU-Diary study: prospective, multicenter comparative study of the impact of an ICU diary on the wellbeing of patients and families in French ICUs

BACKGROUND

Post-intensive care syndrome includes the multiple consequences of an intensive care unit (ICU) stay for patients and families. It has become a new challenge for intensivists. Prevention programs have been disappointing, except for ICU diaries, which report the patient's story in the ICU. However, the effectiveness of ICU diaries for patients and families is still controversial, as the interpretation of the results of previous studies was open to criticism hampering an expanded use of the diary. The primary objective of the study is to evaluate the post-traumatic stress syndrome in patients. The secondary objectives are to evaluate the post-traumatic stress syndrome in families, anxiety and depression symptoms in patients and families, and the recollected memories of patients. Endpoints will be evaluated 3 months after ICU discharge or death.

METHODS

A prospective, multicenter, randomized, assessor-blind comparative study of the effect of an ICU diary on patients and families. We will compare two groups: one group with an ICU diary written by staff and family and given to the patient at ICU discharge or to the family in case of death, and a control group without any ICU diary. Each of the 35 participating centers will include 20 patients having at least one family member who will likely visit the patient during their ICU stay. Patients must be ventilated within 48 h after ICU admission and not have any previous chronic neurologic or acute condition responsible for cognitive impairments that would hamper their participation in a phone interview. Three months after ICU discharge or death of the patient, a psychologist will contact the patient and family by phone. Post-traumatic stress syndrome will be evaluated using the Impact of Events Scale-Revised questionnaire, anxiety and depression symptoms using the Hospital Anxiety and Depression Scale questionnaire, both in patients and families, and memory recollection using the ICU Memory Tool Questionnaire in patients. The content of a randomized sample of diaries of each center will be analyzed using a grid. An interview of the patients in the intervention arm will be conducted 6 months after ICU discharge to analyze in depth how they use the diary.

DISCUSSION

This study will provide new insights on the impact of ICU diaries on post-traumatic stress disorders in patients and families after an ICU stay.

TRIAL REGISTRATION

ClinicalTrial.gov, ID: NCT02519725 . Registered on 13 July 2015.

Evaluation of endothelial biomarkers as predictors of organ failures in septic shock patients

BACKGROUND

Endothelial injury is recognized to trigger organ failures during the first 48h of septic shock. We evaluate endothelial biomarkers at ICU admission in their ability to predict severity, outcome, and organ failures in septic shock patients.

METHODS

This prospective observational pilot study was conducted in a medical intensive care unit of a university hospital. Plasma levels of endothelial biomarkers as angiopoietin-2, sE-selectin or endocan were measured at ICU admission of 20 patients presenting with septic shock. Clinical and biological data were recorded at inclusion and each day during the first week.

RESULTS

Significant correlations were found between angiopoietin-2 and severity scores at Day 1: SAPS2 (r(2)=0.620; p=0.004) and LOD score (r(2)=0.681; p=0.001). The angiopoietin-2 level was significantly higher in patients presenting with organ failure such as hemodynamic, renal or hepatic failure. It correlated with catecholamine infusion dose and was higher in non survivors compared with survivors (33.5 [28.9-51.4] vs. 12.4 [6.4-14.7]ng/ml; p=0.001). In contrast, in that population presenting with septic shock, endocan level at inclusion was not related to any organ failure at inclusion or Day 1 but appeared lower in patients presenting with respiratory failure at Day 3 compared to those who do not (1.9 [0.99-3.1] vs 5.2 [3.1-17.2]ng/ml; p=0.032). The endocan level at inclusion was correlated with the decrease in PaO2/FiO2 ratio at Day 2 (r(2)=0.628; p=0.0004) and Day 3 (r(2)=0.645; p=0.005). Endocan level <2.54ng/ml at admission is predictive of a respiratory failure presence at Day 3.

CONCLUSION

In septic shock patients, angiopoietine-2 is related with clinical severity during the first 24h but only endocan is able to predict the presence of respiratory failure at Day 3.

Kinetics and pattern of viral excretion in biological specimens of two MERS-CoV cases

•

Lower respiratory tract excretion of MERS-CoV can be observed for more than one month.

•

Viral excretion in multiple organs is possible, including viraemia.

•

Prolonged infection prevention and control measures are necessary.

•

Prolonged monitoring of respiratory excretion seems necessary.

Background

Middle East respiratory syndrome coronavirus (MERS-CoV) is an emerging coronavirus involved in severe acute respiratory distress syndrome (ARDS) and rapid renal failure. Hospital outbreak and nosocomial transmission were reported, however, several issues remain on the viral excretion course.

Objectives

Describe the kinetics and pattern of viral excretion in two infected patients.

Study design

After the initial diagnosis, blood, urine, rectal and respiratory samples were collected regularly, aliquoted and stored at −80 °C. Real-time reverse transcriptase polymerase chain reaction assay targeted the UpE and Orf1a regions of the MERS-CoV genome.

Results

In patient 1, who died of refractory ARDS and renal failure, MERS-CoV RNA was detected in pharyngeal and tracheal swabs, as well blood samples and urine samples until the 30th day. Rectal swabs were negative. Patient 2 also developed multiple-organ failure, but survived, with persisting renal insufficiency (creatinine clearance at 30 mL/min) and persistent interstitial syndrome albeit weaned off mechanical ventilation and no longer requiring oxygen. Tracheal aspirations were positive until the 33rd day, while nasopharyngeal swabs were negative. All other biological samples were negative.

Discussion

Lower respiratory tract excretion of MERS-CoV could be observed for more than one month. The most severely ill patient presented an expression of the virus in blood and urine, consistent with a type-1 interferon mediated immunological response impaired in patient 1, but developed by patient 2. These results suggest that infection control precautions must be adequately evaluated in clinical wards and laboratories exposed to MERS-CoV.

Factors predicting prolonged empirical antifungal treatment in critically ill patients

Objective

To determine the incidence, risk factors, and impact on outcome of prolonged empirical antifungal treatment in ICU patients.

Methods

Retrospective observational study performed during a one-year period. Patients who stayed in the ICU >48 h, and received empirical antifungal treatment were included. Patients with confirmed invasive fungal disease were excluded. Prolonged antifungal treatment was defined as percentage of days in the ICU with antifungals > median percentage in the whole cohort of patients.

Results

Among the 560 patients hospitalized for >48 h, 153 (27%) patients received empirical antifungal treatment and were included in this study. Fluconazole was the most frequently used antifungal (46% of study patients). Median length of ICU stay was 19 days (IQR 8, 34), median duration of antifungal treatment was 8 days (IQR 3, 16), and median percentage of days in the ICU with antifungals was 48% (IQR 25, 80). Seventy-seven patients (50%) received prolonged empirical antifungal treatment. Chemotherapy (OR [95% CI] 2.6 [1.07-6.69], p = 0.034), and suspected infection at ICU admission (3.1 [1.05-9.48], p = 0.041) were independently associated with prolonged empirical antifungal treatment.

Duration of mechanical ventilation and ICU stay were significantly shorter in patients with prolonged empirical antifungal treatment compared with those with no prolonged empirical antifungal treatment. However, ICU mortality was similar in the two groups (46 versus 52%, p = 0.62).

Conclusion

Empirical antifungal treatment was prescribed in a large proportion of study patients. Chemotherapy, and suspicion of infection at ICU admission are independently associated with prolonged empirical antifungal treatment.

Accuracy of leptin serum level in diagnosing ventilator-associated pneumonia: a case-control study

BACKGROUND

Undernutrition causes a reduction of body-fat mass and a decrease in the circulating concentration of leptin which impairs the production of proinflammatory cytokines and increases the incidence of infectious diseases. The main objective of this study was to determine whether leptin deficiency is a risk factor for ventilator-associated pneumonia (VAP).

METHODS

This prospective observational case-control study was conducted in a university ICU during a 2-year period. Patients with VAP (cases) were matched (1:1) to patients without VAP (controls) according to all the following criteria: age, gender, SAPS II, and duration of ICU stay before VAP occurrence. In all patients leptin, C-reactive protein (CRP) and procalcitonin (PCT) were measured at ICU admission, and twice a week. In addition, in cases, leptin, CRP and PCT were also measured on the day of VAP diagnosis.

RESULTS

Eighty-six cases were matched with 86 controls. No significant difference was found in leptin and PCT levels between cases and controls. CRP level was significantly higher on the day of VAP in cases compared with controls (99 vs. 48 mg/L, P=0.001). Combination of CRP-leptin (CRP ≥78 mg/L and leptin ≥6.2 ng/mL on the day of VAP) was significantly (P=0.009) associated with VAP in univariate analysis. Multivariate analysis identified the combination of CRP-leptin (OR [95% CI] 3.08 [1.18-8.04], P=0.003), LOD score (1.27 [1.08-1.48], P=0.003), neuromuscular-blockers use (6.6 [2.03-21.7], P=0.002), and reintubation (3.3 [1.14-9.6], P=0.027) as independent risk factors for VAP.

CONCLUSION

In our study, leptin level was not associated with VAP occurrence. Further studies are needed to confirm our results, and to define the exact inflammatory role of leptin, and its interest as a biomarker in ICU patients.

Adverse events during intrahospital transport of critically ill patients: incidence and risk factors

Background

Transport of critically ill patients for diagnostic or therapeutic procedures is at risk of complications. Adverse events during transport are common and may have significant consequences for the patient. The objective of the study was to collect prospectively adverse events that occurred during intrahospital transports of critically ill patients and to determine their risk factors.

Methods

This prospective, observational study of intrahospital transport of consecutively admitted patients with mechanical ventilation was conducted in a 38-bed intensive care unit in a university hospital from May 2009 to March 2010.

Results

Of 262 transports observed (184 patients), 120 (45.8%) were associated with adverse events. Risk factors were ventilation with positive end-expiratory pressure >6 cmH₂O, sedation before transport, and fluid loading for intrahospital transports. Within these intrahospital transports with adverse events, 68 (26% of all intrahospital transports) were associated with an adverse event affecting the patient. Identified risk factors were: positive end-expiratory pressure >6 cmH₂O, and treatment modification before transport. In 44 cases (16.8% of all intrahospital transports), adverse event was considered serious for the patient. In our study, adverse events did not statistically increase ventilator-associated pneumonia, time spent on mechanical ventilation, or length of stay in the intensive care unit.

Conclusions

This study confirms that the intrahospital transports of critically ill patients leads to a significant number of adverse events. Although in our study adverse events have not had major consequences on the patient stay, efforts should be made to decrease their incidence.

Pseudomembranous colitis due to Clostridium difficile as a cause of perineal necrotising fasciitis

Although rare, pseudomembranous colitis may be a cause of perineal necrotising fasciitis in a context of immunosuppression, as in the case we report. This origin must be quickly identified because the therapeutic management, especially surgery, is unlikely to be the same as usual. Similarly, antibiotic treatment is also a matter of discussion due to the potential deleterious role of antibiotics in pseudomembranous colitis.

Effects of infliximab therapy on abdominal fat and metabolic profile in patients with Crohn's disease

BACKGROUND

Tumor necrosis factor is an adipocytokine possessing a well-established lipolytic effect. In Crohn's disease (CD) patients, infliximab therapy may thus result in visceral fat accumulation, which is associated with an increased risk of metabolic syndrome.

METHODS

A total of 132 CD patients were investigated. In a first prospective study, magnetic resonance imaging (MRI) quantification of subcutaneous and visceral abdominal fat was performed before and 8 weeks after initiation of infliximab induction therapy (5 mg/kg at weeks 0, 2, and 6) in 21 responding patients treated for perianal disease. In a second prospective study, fasting glycemia, glycated hemoglobin (HbA1c), HDL, LDL, and total cholesterol and triglyceride levels were assessed in 111 responding patients receiving infliximab infusions every 8 weeks, with a mean follow-up of 41 weeks.

RESULTS

A significant homogeneous 18% increase in total abdominal fat was observed in the 21 CD patients after infliximab induction therapy (P = 0.027), independently of body mass index evolution. Infliximab maintenance therapy was associated with a decrease in glycemia (P < 0.0001) and HbA1c (P = 0.0005) concentrations, together with an increase in both total cholesterol (P = 0.02) and HDL cholesterol (P = 0.008) concentrations. All glycemic and lipid parameters remained within the normal range throughout the study.

CONCLUSIONS

Infliximab induction therapy is associated with a significant increase in abdominal fat tissue in CD patients. Infliximab maintenance therapy has no deleterious effects on lipid profile and is accompanied by a decrease in glycemia and HbA1c concentrations, probably by reversing the impairment of tumor necrosis factor-induced insulin-mediated glucose uptake.