An original risk score to predict early major bleeding in acute pulmonary embolism: the Syncope, Anemia, Renal Dysfunction (PE-SARD) bleeding score

Background

Improved prediction of the risk of early major bleeding in pulmonary embolism (PE) is needed to optimize acute management.

Methods

Using data from a multicenter prospective registry including 2,754 patients, we performed multivariable logistic regression analysis to build a risk score to predict early (up to hospital discharge) major bleeding events. We validated the endpoint model internally using bootstrapping in the derivation dataset by sampling with replacement for 500 iterations. We compared the performance of this novel score to that of the VTE-BLEED and RIETE models.

Results

Multivariate regression identified three predictors for the occurrence of 82 major bleeds (3.0%): Syncope (+1.5 points), Anemia defined by a hemoglobin level <12 g/dL (+2.5 points), and Renal Dysfunction defined by a glomerular filtration rate <60 mL/min (+1 point). The PE-SARD bleeding score was calculated by summing all the components. Overall, 52.2% of patients were classified as low bleeding-risk (score, 0 point), 35.2% intermediate-risk (score, 1–2.5 points), and 12.6% high-risk (score >2.5 points). Cumulative observed bleeding rates increased with increasing risk group, from 0.9% in the low-risk group to 9.0% in the high-risk group. The C-index was 0.744 (95% CI, 0.73–0.76) and Brier score 0.028 in the derivation cohort. Similar values were calculated from internal bootstrapping. Performance of the PE-SARD score was better than that observed with the VTE-BLEED and RIETE scores (figure).

Conclusions

The PE-SARD bleeding risk score is an original, user-friendly score to estimate the risk of early major bleeding in patients with acute PE.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Renal function improves mortality prediction in acute pulmonary embolism: results of a multicentre cohort study with external validation in the RIETE registry

Background

Renal dysfunction may influence outcomes after pulmonary embolism (PE). We determined the incremental value of adding renal function impairment (estimated glomerular filtration rate, eGFR <60 ml/min/1.73m2) on top of the 2019 ESC prognostic model, for the prediction of 30-day all-cause mortality in acute PE patients from a prospective, multicenter cohort.

Methods and results

We identified which of three eGFR formulae predicted death most accurately. Changes in global model fit, discrimination, calibration and net reclassification index (NRI) were evaluated with addition of eGFR. We prospectively included consecutive adult patients with acute PE diagnosed as per ESC guidelines. Among 1,943 patients, (mean age 67.3±17.1, 50.4% women), 107 (5.5% (95% CI 4.5–6.5%)) died during 30-day follow-up. The eGFRMDRD4 formula was the most accurate for prediction of death. The observed mortality rate was higher for intermediate-low risk (OR 1.8, 95% CI 1.1–3.4) and high-risk PE (OR 10.3, 95% CI 3.6–17.3), and 30-day bleeding was significantly higher (OR 2.1, 95% CI 1.3–3.5) in patients with vs without eGFRMDRD4 <60 ml/min/1.73m2. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC models. NRI was significantly improved (p<0.001), with 18% reclassification of predicted mortality, specifically in intermediate and high-risk PE. External validation using data from the RIETE registry confirmed our findings (Table).

Conclusion

Addition of eGFRMDRD4-derived renal dysfunction on top of the ESC prognostic algorithm yields significant reclassification of risk of death in intermediate and high-risk PE. Impact on therapy remains to be determined.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer Alliance, Bayer Healthcare

P2767Outcomes and incremental prognostic value of renal function impairment after acute pulmonary embolism

Background

We explored the relation between adverse outcomes after acute pulmonary embolism (PE)and renal dysfunction classified by estimated glomerular filtration rate (eGFR) using the CKD-EPI equation. We assessed the incremental value of adding eGFR CKD-EPI to the ESC score for predicting 30d mortality.

Methods

Prospective, multicenter study of 1664 acute PE admitted from 01/2011 to 12/2017. Pts were categorized in 4 eGFR groups: Group 1 (eGFR ≥60 ml/min/1.73m2, n=1178), group 2 (45–59; n=257); group 3 (30–44; n=150), group 4 (≤29; n=79).

Results

All-cause and CV death at 30 days and 6 months were higher in group 3 (p=0.005 and p=0.03) and group 4 (p<0.001 and p<0.001 respectively) vs group 1. Major bleeding at 30d and 6m was higher in group 2 vs group 1 (p=0.003 for both). Renal dysfunction combined with the ESC prognostic algorithm for prediction of 30d death improved discriminatory capacity of the model and enabled reclassification in different risk categories in 27% of pts (Table).

Without eGFR CKD-EPI OR (95% CI) With eGFR CKD-EPI OR (95% CI) ESC algorithm 2.59 (1.95–3.43) 2.30 (1.72–3.07) eGFR CKD-EPI – 2.60 (1.62–4.7) Measures of fit   Bayes information criterion 607.30 599.32   Akaike information criterion 596.47 583.06   C-statistic 0.71* 0.77*   P (Hosmer-Lemeshow) 0.057 0.43   Integrated discrimination improvement – 0.054 (0.052–0.056)   Net reclassification improvement – 0.93 (0.90–0.95) Prognostic performance   Sensitivity 62.5 (51.2–72.3) 76.2 (61.5–90.2)   Specificity 64.2 (49.1–74.4) 69.9 (47.6–83.5)   Positive predictive value 10.1 (8.2–11.3) 16.2 (14.2–18.2)   Negative predictive value 0.97 (0.96–0.98) 98.1 (97.2–99.2)   Positive likelihood ratio 1.96 (1.12–3.41) 2.12 (1.54–3.12)   Negative likelihood ratio 0.50 (0.25–1.81) 0.54 (0.20–1.56)   Youden index 0.31 (0.28–0.34) 0.39 (0.36–0.41) Difference in C-statistic: *p=0.04.

Conclusion

Renal function impairment increases the rate of adverse events after acute PE. Combined with the ESC early mortality risk score, eGFR improves risk classification.

[Extracorporeal CO2 removal as life support system for a severe organizing pneumonia]

INTRODUCTION

Acute lung injuries are usually found in intensive care unit. The diffuse alveolar damage (DAD) is the associated histological pattern and the most severe end-stage of the disease. Organizing pneumonia (OP), for which corticosteroids are the reference therapy, can mimic DAD. While postponing the response to treatment, to limit mechanical ventilation side effects, extracorporeal membrane oxygene can be proposed. We present a case of a severe OP for which extracorporeal CO₂ removal (ECCO₂R) is used as a bridge to recovery under corticosteroid therapy.

CASE REPORT

In the context of a flu-like syndrome, the non-recovery of a lung impairment is reported to a severe OP. ECCO₂R is applied when using an ultraprotective ventilation and while waiting for lung healing under corticosteroid. This strategy allowed successful recovery, early physical therapy and active mobilization.

CONCLUSION

This observation presents the diagnostic and therapeutic difficulties of the lung parenchymental disease in intensive care. OP must be recognized. ECCO₂R can be used in severe OP as a bridge to recovery while waiting for the corticosteroid efficacy.

[Not Available]

This is an epidemiologic study of the need for Health Services for burns in the northern part of Franche Comté (north-east of France) along year 2014 (114 patients). Mean age was 26 years (8 month-81 years), one third of burns occurred in children below 15. Most burns take part in summer, around mealtime, in "school-free" days, at home and are scalds. Their surface is low (4,81%) and they are usually partial thickness ones. Patients are consulted in Emergency Department in 88,59% of the cases, and hospitalised thereafter in a Burns Unit (in Lyon more than Nancy or Metz) in 12,28%.

[The ABLE study: A randomized controlled trial on the efficacy of fresh red cell units to improve the outcome of transfused critically ill adults]

Red blood cell units are stored up to 42 days post-collection. The standard policy of blood banks is to deliver the oldest units in order to limit blood wastage. Many caregivers believe that giving fresh rather than old units can improve the outcome of their transfused patients. The ABLE study aims to check if the transfusion of red blood cell units stored seven days or less (fresh arm) improve the outcome of transfused critically ill adults compared to patients who received units delivered according to the standard delivery policy (control arm). From March 2009 to May 2014, 1211 patients were allocated to the fresh arm, 1219 to the control arm (length of storage: 6.1 ± 4.9 and 22.0 ± 8.4 days respectively, P<0.001). The primary outcome measure was 90-day all-cause mortality post-randomisation: there were 448 deaths (37.0%) in the fresh arm and 430 (35.3%) in the control arm (absolute risk difference: 1.7%; 95% confidence interval: -2.1% to 5.5%). In a survival analysis, the risk of death was higher in the fresh arm (hazard ratio: 1.1; 95%CI: 0.9 to 1.2), but the difference was not statistically significant (P=0.38). The same trend against the fresh arm was observed with all but one secondary outcome measures. The conclusion is that the transfusion of red blood cell units stored seven days or less does not improve the outcome of critically ill adults compared to the transfusion of units stored about three weeks (22.0 ± 8.4 days).

Performance of manual ventilation: how to define its efficiency in bench studies? A review of the literature

Bench studies have become the preferred way to evaluate the performance of airway equipment, since clinical trials are not specifically required before marketing these devices. However, it is difficult to assess the efficiency of ventilation without recording physiological data. This review analyses how efficiency of manual ventilation has been defined in recent studies, and how their results may be affected. We searched electronic databases from 2000 to April 2014. The main inclusion criterion was the analysis of performance of ventilation. Nine relevant articles were selected from 53 eligible publications. Most studies used the same parameters; tidal volume and ventilation rate. However, there were significant differences between the definitions of performance of ventilation, both in terms of criteria of judgement and methods of analysis. None of these approaches is able to provide a clear understanding of variability of ventilation during a given period. A new definition may increase the relevance of bench studies to clinical medicine, by more appropriately assessing the performance of ventilation.

Reliability of manikin-based studies: an evaluation of manikin characteristics and their impact on measurements of ventilatory variables

Findings from manikin-based studies on ventilation are commonly directly extrapolated to clinical practice. The aim of this study was to determine how the use of manikins affects measurements of ventilatory variables. We connected a lung simulator to a manikin, which was then ventilated at different inspiratory flows. We defined three experimental models to compare measurements of ventilatory variables between the mechanical ventilator and the lung simulator. Even when no leakage occurred, significant tidal volume deviations were observed; from a mean (SD) of 21 (2) ml to 49 (9) ml, and from 40 (4) ml to 88 (5) ml for invasive and non-invasive ventilation, respectively (p < 0.001). Significant peak pressure deviations from 0.7 (0.1) cmH2 O to 10.6 (0.3) cmH2 O were also recorded during non-invasive ventilation (p < 0.001). Evaluation of manikin resistance and airway dead space may be essential to limit study bias. We suggest a recalibration of the recorded data if comparisons are made between different tests performed at different inspiratory flows.

[Implementation of morbidity and mortality conferences in French intensive care units: a survey]

OBJECTIVE

A national survey was conducted by the "Collège français d'anesthésie et de réanimation (CFAR)" and the "Collège des bonnes pratiques en réanimation (CBPR)", to analyze the implementation of morbidity and mortality conferences (MMCs) in French intensive care units (ICUs).

STUDY DESIGN

An electronic questionnaire was set up. We directed the survey at French ICUs physicians registered in the two Colleges directories, only one form was filled in by each participating unit.

RESULTS

From December 2009 to February 2010, Among the 170 replies, 120 ICUs (71%) practiced MMC. No difference in the typology of the two groups was found. The median annual number of MMCs was 4 per year (1-15). The perimeter of the MMCs concerned only the ICU unit in 70 cases (58%), more than one ICU unit in the same department in 11 cases (9.8%), more than one department of ICU in 16 cases (13%) and other departments in 57 cases (48%). The events analyzed were: all deaths in 45 cases (37.5%), unexpected deaths in 50 cases (41.7%), severe adverse events in 67 cases (55.8%) and other events in 19 cases (15.8%). At least one adverse event defined by the two colleges in the process of "accreditation" was analyzed in 86 cases (72%). Participation of a physician of at least one other unit was reported in 56 cases (47%) and of medical students in 62 cases (52%). The low rate of participation of ICU nurses was reported in 62 cases (69.2%) and their absence in 35 cases (29%). MMCs consequences were drafting of new procedure in 99 cases (83%), changes in procedures in 75 cases (63%), conducting training programs in 60 cases (50%), organizational changes in 86 cases (72%), adverse event declaration in 21 cases (18%) and monitoring indicators in 40 cases (33%). Among units which did not practice MMCs, Identified obstacles were organizational causes in 25 cases (50%), inexperience in seven cases (14%), lack of methodology in 4 cases (8%), realization of other methods of formative assessment in 4 cases (8%) and physician's refusal in three cases (6%). The fear of medico-legal problem was never reported as a barrier to MMCs practice. Forty-five units (90%) projected to practice MMR.

CONCLUSION

This survey showed that the practice of MMR is common in French ICUs, allowing the identification of organizational problems, but also of training needs, joining one of the initial concerns that have led to their implementation. Expanding the participation to non-physician members of the units should be encouraged, without underestimating the difficulties particularly in the organizational domains that represent an obstacle to development of MMCs.

A successful renal transplantation for renal failure after dasatinib-induced thrombotic thrombocytopenic purpura in a patient with imatinib-resistant chronic myelogenous leukaemia on nilotinib

Second-generation tyrosine kinase inhibitors (TKI2) often induce molecular remission, and prolonged survival with a better tolerance in imatinib-resistant chronic myelogenous leukaemia (CML) patients. We report the case of a CML in first chronic phase who was diagnosed in August 2003 in a young 24 year-old Caucasian woman. Our patient received first imatinib and then dasatinib and nilotinib. Imatinib was well tolerated and she developed TTP/HUS on dasatinib without documented evolution of CML and finally obtained MR5.0 with nilotinib and without any side effect. This case also illustrates the absence of cross-resistance and side-effects between the different TKIs and the feasibility of kidney transplantation associated with a nilotinib treatment of CML allowing a continuing MR5.0 and no further side effects.

Successful organ transplantation after treatment of fatal cyanide poisoning with hydroxocobalamin

BACKGROUND

Cyanide-poisoned patients are potential organ donors provided that organs are not damaged by the poison or by antidotal treatment.

CASE STUDY

A patient with third-degree burns and smoke inhalation-associated cyanide poisoning confirmed by measurements of whole blood cyanide was found in cardiac arrest and administered epinephrine and hydroxocobalamin (5 g + 5 g). Cardiac activity resumed, but the patient was declared brain dead on the third day of hospitalization when coma deteriorated to a shock state with refractory hypoxemia. Kidneys, heart, and liver were removed and transplanted into four patients. Gross pre-transplantation inspection of the donor organs and renal histology showed no evidence that hydroxocobalamin caused organ toxicity. Donor organs functioned normally through follow-up periods of several months.

CONCLUSION

Anoxic cardiac arrest following acute cyanide poisoning treated with hydroxocobalamin (5 g + 5 g) was not a contraindication to organ transplantation after confirmed encephalic death in this patient.

[Pseudomonas aeruginosa epidemiology in intensive care units: importance of cross-transmission]

OBJECTIVES

To update the local epidemiological data of Pseudomonas aeruginosa in intensive care units (ICU) by assessing the colonisation incidence rate and the level of cross-transmission.

METHODS

Study carried out in both adult ICUs of the university-hospital of Besançon during a 2 years period. Clinical and surveillance specimens were screened for P. aeruginosa. Pulsed-field-gel-electrophoresis was used as genotyping method to evaluate the rate of cross-transmission.

RESULTS

During the study, 314 patients were positive for P. aeruginosa (incidence rate of 19.1 patients per 100 admitted patients). One hundred sixty-six of these patients were detected with a clinical specimen and 148 with a screening specimen. Seventy-seven patients were colonised upon admission in the intensive care unit and 237, negative on admission, became positive during their stay. Of the ICU-acquired cases, the mean length of stay before P. aeruginosa colonisation was acquired was 15.7 days. Genotyping revealed that 53.5% of P. aeruginosa colonisation was acquired via cross-transmission (respectively 48.1% in the medical ICU and 59.2% in the surgical ICU); the other cases probably originated from endogenous sources.

CONCLUSION

The incidences of P. aeruginosa colonisation upon admission and during hospitalisation are consistent with other french and european studies. Although we probably over-estimated the rate of cross-transmission, our results demonstrate that cross-transmission may be a major cause of P. aeruginosa dissemination in ICUs.

Cost-effectiveness of urinary dipsticks to screen asymptomatic catheter-associated urinary infections in an intensive care unit

OBJECTIVE

To assess the cost-effectiveness of urinary dipsticks (UDs) to screen asymptomatic catheterized patients for quantitative urine.

DESIGN

Prospective comparison of UD with quantitative urine culture (QUC) (reference technique) and cost-effectiveness analysis performed from the hospital's perspective.

SETTING

Medical intensive care unit (ICU) of the Besançon University Hospital (France).

PATIENTS AND PARTICIPANTS

All consecutive, asymptomatic, catheterized patients.

INTERVENTIONS

Urinary dipsticks (Multistix 8-SG) were analyzed by the reflectance spectrophotometric method (Clinitek 50). Sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of four combinations of the leukocyte (L) test pad and the nitrite (N) test pad were calculated: L and N, L or N, L alone and N alone. A micro-costing technique was used to determine the direct medical cost of each strategy. The calculated cost-effectiveness ratio was the incremental cost-effectiveness (ICE) ratio.

MEASUREMENTS AND RESULTS

Three hundred thirty-nine urine samples taken from 144 patients were analyzed. The incidence of asymptomatic catheter-associated urinary tract infections (CAUTIs) was 31.3% (> or =10(5) organisms/ml). The L or N combination was the best detector of asymptomatic CAUTI: Se=87.2%, Sp=61.6%, PPV=30.6% and NPV=96.1%. The cost of QUC strategy and UD strategy was EUR 21.5 and EUR 12.6 per test, respectively. The ICE ratio of QUCs was EUR 69.5 per case of detected CAUTI.

CONCLUSION

The UD is a cost-effective test for screening asymptomatic catheterized patients for quantitative urine culture in a medical ICU.

Endemicity, molecular diversity and colonisation routes of Pseudomonas aeruginosa in intensive care units

OBJECTIVE

We carried out a prospective study to evaluate the endemicity of Pseudomonas aeruginosa in intensive care units (ICUs). Pulsed-field gel electrophoresis (PFGE) was used to determine the genotypes of P. aeruginosa isolates. This allowed us to determine the importance of cross-colonisation and the colonisation routes of P. aeruginosa.

DESIGN

We screened epidemiological specimens (rectal swab, nose swab and tracheal aspiration) and routine clinical cultures from patients admitted to ICUs during a 2-year period, from 1st January, 1998, to 31st December, 1999.

SETTING

The study was carried out in four separate adult ICUs located in the Franche-Comté region of France. These four units admitted a total of 1,500 patients per year.

RESULTS

A total of 1686 specimens were collected from 473 patients; 122 of these patients were positive on admission, 351 became positive during hospitalisation. The overall incidence of P. aeruginosa was 15.7 cases per 100 patients and 15.1 cases per 1000 days of hospitalisation. Of 184 patients with at least one ICU-acquired positive clinical culture, 104 had been previously identified as carriers by a similar genotype. Typing of 208 non-replicate isolates revealed 101 major DNA patterns. Approximately 50% of P. aeruginosa carriage or colonisation/infection was acquired via cross-transmission; the other cases probably originated from endogenous sources.

CONCLUSION

Cross-colonisation seems to play an important role in the general spread of P. aeruginosa in ICUs.

Risk factors for catheter-associated bacteriuria in a medical intensive care unit

In a prospective study including 137 consecutive catheterised patients in a medical intensive care unit, the following variables were analysed as possible risk factors for catheter-associated bacteriuria, defined as a quantitative culture with > or = 10(5) organisms/ml: age, sex, simplified acute and physiologic score at admission, duration of catheterisation, diabetes mellitus, immunosuppression, neurologic disorders and prior systemic antibiotic exposure during hospitalisation. The frequency of catheter-associated bacteriuria was 30.7%. By multivariate analysis, female sex (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.9-13.5; P=0.001) and a duration of catheterisation >11 days (OR, 19.4; 95% CI, 5.5-68.7; P=0.0001) were risk factors for catheter-associated bacteriuria, and prior antibiotic exposure was a protective factor (OR, 0.06; 95% CI, 0.019-0.21; P=0.0001).

[Severe obstetric complications nescessitating hospitalization and intensive care: a ten year retrospective study]

OBJECTIVES

To assess the serious maternal morbidity during pregnancy, delivery and post partum, which led to an hospitalization in a medical or surgical intensive care unit.

STUDY DESIGN

A Retrospective study was carried out on a period of ten years, from July 1986 to July 1996, in the University Teaching Hospital of Besançon.

PATIENTS

The criterions of inclusion come from the definition of the serious maternal morbidity decided by the Inserm: any admission of a pregnant woman in a medical or surgical intensive care unit in the 42 days of the post-partum, whatever the term of the pregnancy and the type of the post-partum, extra uterine pregnancy, spontaneous miscarriage and medical or voluntary abortion.

METHODS

Forty-six patient's medical file hospitalized in a medical or surgical intensive care unit between July, 1st 1986 and July, 31st 1996, have been studied.

RESULTS

The analysis of the cause underline the gravity of the pathologies handled with young patients and initially healthy, the short length of controlled ventilation and hospitalization, the avoidability of great number of transfer in an intensive care unit, and the lack of hospitalization due to anaesthesia. The frequency of hospitalisation in an intensive care unit during and after the pregnancy was estimated at 0.17% of lives births.

CONCLUSION

The serious maternal morbidity could be an indicator of the quality of the obstetrics cares which would complete the study of the maternal mortality. The potential gravity of the complication of the pregnancy and the delivery require better care of this patients.

Predictive factors of death in primary lung cancer patients on admission to the intensive care unit

OBJECTIVE

To assess the lung cancer patient's prognosis in the intensive care unit with early predictive factors of death.

DESIGN

Retrospective study from July 1986 to February 1996.

SETTING

Medical intensive care unit at a university hospital.

PATIENTS

Fifty-seven patients with primary lung cancer admitted to our medical intensive care unit (MICU).

MEASUREMENTS AND RESULTS

Data collection included demographic data (age, sex, underlying diseases, MICU admitting diagnosis) and evaluation of tumor (pathologic subtypes, metastases, lung cancer staging, treatment options). Three indexes were calculated for each patient: Karnofsky performance status, Simplified Acute Physiology Score (SAPS) II, and multisystem organ failure score (ODIN score). Mortality was high in the MICU: 66% of patients died during their MICU stay, and hospital mortality reached 75%. In multivariate analysis, acute pulmonary disease and Karnofsky performance status < 70 were associated with a poor MICU and post-MICU prognosis. For the survivors, long-term survival after MICU discharge depended exclusively on the severity of the lung cancer.

CONCLUSIONS

We confirmed the high mortality rate of lung cancer patients admitted to the MICU. Two predictive factors of death in MICU were identified: performance status < 70 and acute pulmonary disease.