Search

Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock.This was a retrospective and observational study.University hospital.The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock.The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI18.5 kg/m²), 62 were normal weight (BMI = 18.5-24.9 kg/m²), 34 were overweight (BMI = 25.0-29.9 kg/m²), 34 were obese class I (BMI = 30.0-34.9 kg/m²), and 10 were obese class II (BMI = 35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p = 0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p = 0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p = 0.07). No statistically significant differences were found among BMI categories in the incidences of complications.The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.

Background The Coronavirus 2019 (COVID-19) pandemic has had a considerable impact on the incidence of severe community-acquired pneumonia (CAP) worldwide. The aim of this study was to assess the early impact of the COVID-19 pandemic on severe CAP in the Reunion Island. Material and methods This multicenter retrospective observational study was conducted from 2016 to 2021 in the hospitals of Reunion Island. The incidence of severe CAP, microorganisms, the characteristics and outcomes of patients hospitalized in intensive care unit were compared between the pre-COVID-19 period (January 1, 2016 to February 29, 2020) and the early COVID-19 period (March 1, 2020 to October 31, 2021). Results Over the study period, 389 patients developed severe CAP. The incidence of severe CAP significantly decreased between the two periods (9.16 vs. 4.13 cases per 100,000 person-years). The influenza virus was isolated in 43.5% patients with severe CAP in the pre-COVID-19 period and in none of the 60 patients in the early COVID-19 period (P Streptococcus pneumoniae was the most frequently isolated bacterial microorganism, with no significant difference between the two periods. Conclusion In Reunion Island, the COVID-19 pandemic led to a significant decrease in the incidence of influenza, which likely explains the observed decrease in the incidence of severe CAP. The pandemic had no impact on the incidence of bacterial severe CAP. The incidence of influenza needs to be closely monitored now that control measures against COVID-19 have been removed.

Dengue disease is found worldwide and has been spreading exponentially in the past decades. Severe forms affect about 2% of patients, sometimes leading to organ failure. Recent studies have shown that fulminant dengue myocarditis is more common than previously thought, and fatal cases have been reported. The treatment of fulminant dengue myocarditis remains supportive and is very challenging in cases of cardiogenic shock. Here, we describe four cases presenting with fulminant dengue myocarditis treated with extracorporeal membrane oxygenation, among two survived.

Background Pneumonia is a frequent complication in patients undergoing heart transplantation (HTx) that increases morbidity and mortality in this population. Nevertheless, the risk factors for postoperative pneumonia (POP) are still unknown. The aim of this study was to investigate the predictive risk factors for POP in HTx recipients. Methods In this retrospective study, all patients undergoing HTx between January 2014 and December 2015 were included. All cases of POP occurring until hospital discharge were investigated. The study aimed to determine risk factors using univariate and multivariate Cox regression models. Data are expressed in Odds Ratio [95% CI]. P Results A total of 175 patients were included without any patients being lost to follow-up, and 89 instances of POP were diagnosed in 59 (34%) patients. Enterobacteriaceae and Pseudomonas aeruginosa were the most common pathogens. In the multivariate analysis, the risk factors were preoperative mechanical ventilation (OR 1.42 [1.12–1.80], P P P = 0.01) and 1 year (OR: 6.8 [2.5–8.4], P Conclusion After HTx, preoperative mechanical ventilation and blood transfusion were risk factors for POP and were associated with increased mortality. Enterobacteriaceae and Pseudomonas aeruginosa are the most common pathogens of POP.

Background: The incidence of ventilator-associated pneumonia caused by Stenotrophomonas maltophilia (SM-VAP) is on the rise. This pathology is associated with increased morbidity and mortality in intensive care unit (ICU), notably due to intrinsic resistance and ineffective probabilistic antibiotic therapy. Our study aimed to determine the risk factors for a first episode of SM-VAP in ICU.Methods: This single center retrospective study was conducted from 2010 to 2018 in the polyvalent ICU of Félix Guyon University Hospital in Reunion Island. All patients who developed ventilator-associated pneumonia (VAP) during their ICU stay were consecutively evaluated. Patients with a first episode of SM-VAP were compared to those with a first episode of VAP caused by another microorganism. Results: A total of 89 patients developed a first episode of SM-VAP over the study period. In the group of patients with SM-VAP, infection was polymicrobial in 43.8% of cases and ICU mortality was 49.4%. After multivariate logistic regression analysis, the risk factors for a first episode of SM-VAP were: chronic respiratory failure (Odds Ratio (OR): 4.212; 95% Confidence Interval (CI): 1.776 – 9.989; p = 0.001), chronic renal failure (OR: 2.693; 95% CI: 1.356 – 5.352; p = 0.05), use of third-generation cephalosporins active against Pseudomonas aeruginosa (OR 2.862; 95% CI: 1.505 – 5.442; p = 0.001), and female sex (OR: 2.646; 95% CI: 1.458 – 4.808; p = 0.001). Conclusion: In our study, chronic respiratory failure, chronic renal failure, use of third-generation cephalosporins active against P. aeruginosa, and female sex were identified as risk factors for a first episode of SM-VAP.

Background: The aim of this study was to compare the prognosis of patients with acute respiratory failure (ARF) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant 501Y.V2 to that of patients with ARF due to the original strain. Methods: This retrospective matched cohort study included all consecutive patients who were hospitalized for ARF due to SARS-CoV-2 in Reunion Island University Hospital between March 2020 and March 2021. Twenty-eight in hospital mortality was evaluated before and after matching.Results: A total of 218 patients with ARF due to SARS-CoV-2 were enrolled in the study. Of these, 83 (38.1%) were infected with the 501Y.V2 variant. During intensive care unit stay, 104 (47.7%) patients received invasive mechanical ventilation and 20 (9.2%) patients were supported by venovenous extracorporeal membrane oxygenation. Patients infected with the 501Y.V2 variant were younger (58 [51-68] vs. 67 [56-74] years old, P=0.003), had less hypertension (54.2% vs 68.1%, P=0.04), and had less chronic kidney disease (13.3% vs. 31.9%, P=0.002) than patients infected with the original strain. After controlling for confounding variables (62 matched patients in each group), 28-day mortality was higher in the group of patients infected with the 501Y.V2 variant (30.6%) than in the group of patients infected with the original strain (19.4%, P=0.04).Conclusion: In Reunion Island, where SARS-CoV-2 incidence remained low until February 2021 and the health care system was never saturated, mortality was higher in patients with ARF infected with the 501Y.V2 variant than in patients infected with the original strain.

In February 2021, an explosion of cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia overwhelmed the only hospital in Mayotte. To report a case series of patients with acute respiratory failure (ARF) due to SARS-CoV-2 who were evacuated by air from Mayotte to Reunion Island.This retrospective observational study evaluated all consecutive patients with ARF due to SARS-CoV-2 who were evacuated by air from Mayotte Hospital to the intensive care unit (ICU) of Félix Guyon University Hospital in Reunion Island between February 2, and March 5, 2021.A total of 43 patients with SARS-CoV-2 pneumonia were evacuated by air, for a total flight time of 2 hours and a total travel time of 6 hours. Of these, 38 patients (88.4%) with a median age of 55 (46-65) years presented with ARF and were hospitalized in our ICU. Fifteen patients were screened for the SARS-CoV-2 501Y.V2 variant, all of whom tested positive. Thirteen patients (34.2%) developed an episode of severe hypoxemia during air transport, and the median paO2/FiO2 ratio was lower on ICU admission (140 [102-192] mmHg) than on departure (165 [150-200], P = .022). Factors associated with severe hypoxemia during air transport was lack of treatment with curare (P = .012) and lack of invasive mechanical ventilation (P = .003). Nine patients (23.7%) received veno-venous extracorporeal membrane oxygenation support in our ICU. Seven deaths (18.4%) occurred in hospital.Emergency air evacuation of patients with ARF due to SARS-CoV-2 was associated with severe hypoxemia but remained feasible. In cases of ARF due to SARS-CoV-2 requiring emergency air evacuation, sedated patients receiving invasive mechanical ventilation and curare should be prioritized over nonintubated patients. It is noteworthy that patients with SARS-CoV-2 pneumonia related to the 501Y.V2 variant were very severe despite their young age.

Since 2018, a dengue epidemic has been ongoing in the French overseas department of Reunion Island, in the Indian Ocean, with more than 25,000 serologically confirmed cases. Currently, three dengue serotypes have been identified in Réunion Island (DENV-1, DENV-2, and DENV-3) progressing in the form of epidemic outbreaks. This arbovirus is mainly transmitted by mosquitoes of the genus Aedes and may be responsible for serious clinical forms. To date, very few cases of kidney transplant–related dengue virus infection have been described. Here we report the first case of severe dengue virus infection related to kidney transplantation from a patient previously infected with dengue. Testing for dengue fever with PCR search in donor’s urine may help complete the pretransplant assessment in areas where this disease occurs.

Understanding small remotely piloted aircraft system (sRPAS) to human head impacts is needed to better protect human head during sRPAS ground collision accidents. Recent literature reported cadaveric data on sRPAS to human head impacts, which provided a unique opportunity for developing validated computational models. However, there lacks an understanding of skull stress and brain strain during these impacts. Meanwhile, how slight changes in sRPAS impact setting could affect human head responses remains unknown. Hence, a representative quadcopter style sRPAS finite element (FE) model was developed and applied to a human body model to simulate a total of 45 impacts. Among these 45 simulations, 17 were defined according to cadaveric setting for model validation and the others were conducted to understand the sensitivity of impact angle, impact location, and impacted sRPAS components. Results demonstrated that FE-model-predicted head linear acceleration and rotational velocity agreed with cadaveric data with average predicted linear acceleration 4.5% lower than experimental measurement and average predicted of rotational velocity 2% lower than experimental data. Among validated simulations, high skull stresses and moderate level of brain strains were observed. Also, sensitivity study demonstrated significant effect of impact angle and impact location with 3° variation inducing 30% changes in linear acceleration and 29% changes in rotational velocity. Arm-first impact was found to generate more than two times higher skull stresses and brain strains compared to regular body-shell-first impact.

Deep learning algorithms have shown excellent performances in the field of medical image recognition, and practical applications have been made in several medical domains. Little is known about the feasibility and impact of an undetectable adversarial attacks, which can disrupt an algorithm by modifying a single pixel of the image to be interpreted. The aim of the study was to test the feasibility and impact of an adversarial attack on the accuracy of a deep learning-based dermatoscopic image recognition system. First, the pre-trained convolutional neural network DenseNet-201 was trained to classify images from the training set into 7 categories. Second, an adversarial neural network was trained to generate undetectable perturbations on images from the test set, to classifying all perturbed images as melanocytic nevi. The perturbed images were classified using the model generated in the first step. This study used the HAM-10000 dataset, an open source image database containing 10,015 dermatoscopic images, which was split into a training set and a test set. The accuracy of the generated classification model was evaluated using images from the test set. The accuracy of the model with and without perturbed images was compared. The ability of 2 observers to detect image perturbations was evaluated, and the inter observer agreement was calculated. The overall accuracy of the classification model dropped from 84% (confidence interval (CI) 95%: 82–86) for unperturbed images to 67% (CI 95%: 65–69) for perturbed images (Mc Nemar test, P

This paper proposes a new path planning method for Unmanned Aerial Systems (UAS) flying in a dynamic 3D environment shared by multiple aerial vehicles posing potential conflict risks. It primarily targets applications such as Urban Aerial Mobility (UAM). A new multi-staged algorithm is designed that combines Artificial Potential Field (AFP) method and Harmonic functions with Kalman filtering and Markov Decision Process (MDP) for dynamic path planning. It starts with estimating the aircraft traffic density in the area and then generates the UAS flight path in a way to minimize the risk of encounters. Hardware-in-the-loop simulations of the algorithm in various scenarios are presented, with a RGB-D camera (RealSense™) and Pixhawk autopilot to track the target. Numerical simulations show satisfactory results for path planning in various scenarios with increasing degree of complexity., 2020 International Conference on Unmanned Aircraft Systems (ICUAS), September 1-4, 2020, Athens, Greece

Infection with Leptospira spp. is common in Réunion, a tropical island in the Indian Ocean. However, respiratory coinfections between strains of Leptospira spp. and other microorganisms are rarely described. Here, we describe the first reported case of coinfection between Leptospira spp. and Chlamydia pneumoniae, responsible for refractory acute respiratory distress syndrome requiring extracorporeal membrane oxygenation with a favorable outcome. In a case of leptospirosis with severe respiratory illness, testing for respiratory coinfection, especially with atypical pathogens, could explain the seriousness of the clinical condition and lead to specific treatment.

Background Pneumonia is a frequent complication in patients undergoing heart transplantation (HTx) which increases morbidity and mortality in this population. Nevertheless, risk factors of postoperative pneumonia (POP) are still unknown. The aim of this study was to investigate the predictive risk factors of POP in HTx recipients. Materials and methods In this retrospective study, all patients undergoing HTx between January 2014 and December 2015 were included. All POP occurring until hospital discharge were investigated. The primary end point was the risk factors of POP determined by a Cox model in uni- and multivariate analysis. Data are expressed in OR [95% CI]. P

International audience; BACKGROUND:Staphylococcus aureus has emerged as a leading cause of invasive severe diseases with a high rate of morbidity and mortality worldwide. The wide spectrum of clinical manifestations and outcome observed in staphylococcal illness may be a consequence of both microbial factors and variability of the host immune response.CASE PRESENTATION:A 14-years old child developed limb ischemia with gangrene following S. aureus bloodstream infection. Histopathology revealed medium-sized arterial vasculitis. The causing strain belonged to the emerging clone CC1-MSSA and numerous pathogenesis-related genes were identified. Patient's genotyping revealed functional variants associated with severe infections. A combination of virulence and host factors might explain this unique severe form of staphylococcal disease.CONCLUSION:A combination of virulence and genetic host factors might explain this unique severe form of staphylococcal disease.

Introduction Optimisation of antibiotic therapy for extracorporeal membrane oxygenation (ECMO) patients remains a pharmacological challenge. The objective of this study was to observe the plasma concentrations of commonly used antibiotics in intensive care for patients treated with extracorporeal membrane oxygenation. Patients and methods The PHARMECMO study was a pilot, prospective study, conducted in a cardiac surgery intensive care unit. Every adult patient under ECMO support, with known or suspected sepsis and receiving antibiotic therapy, was eligible for inclusion. Plasma concentrations of antibiotics were determined by a combination of liquid chromatography and mass spectrometry. Results Forty-four eligible patients were enrolled for 68 inclusions on a twelve-month period. For the association piperacillin-tazobactam (n=19), 68.7% of CT50 and 93.7% of Cmin reached the pharmacokinetic goals defined (64 mg.L-1 for CT50 and 16 mg.L-1 for Cmin). For cefotaxime (n=12), the pharmacokinetic goals (4 mg.L-1 for CT50 and 1 mg.L-1 for Cmin) were achieved in 100% of the cases for CT50 and in 81.8% of the cases for Cmin. Regarding imipenem (n=10), the pharmacokinetic goals were 16 mg.L-1 for CT50 and 4 mg.L-1 for Cmin. Only one CT50 was above 16 mg.L-1. For Cmin, 60% of the doses did not reach the target concentration. In our 10 patients, only one patient was considered as reaching the pharmacokinetic goals. Finally, for amikacin (n=6), four Cmax (66.7%) were infra-therapeutics for a target between 60 and 80 mg.L-1. Conclusion These preliminary results suggest that therapeutic drug monitoring could optimise the achievement of pharmacokinetic objectives associated with an effective antibiotic therapy. For most patients, the recommended doses of imipenem and amikacin did not achieve the pK targets

Background Postoperative fluid management can be challenging in children after haemorrhagic surgery. The goal of this study was to assess the ability of dynamic cardiovascular variables measured using bioreactance (NICOM®, Cheetah Medical, Tel Aviv, Israel) to predict fluid responsiveness in postoperative children. Methods Children sedated and mechanically ventilated, who require volume expansion (VE) during the immediate postoperative period, were included. Indexed stroke volume (SVi), cardiac index, and stroke volume variation (SVV) were measured using the NICOM® device. Responders (Rs) to VE were patients showing an increase in SV measured using transthoracic echocardiography of at least 15% after VE. Data are median [95% confidence interval (CI)]. Results Thirty-one patients were included, but one patient was excluded because of the lack of calibration of the NICOM® device. Before VE, SVi [33 (95% CI 31–36) vs 24 (95% CI 21–28) ml m−2; P=0.006] and SVV [8 (95% CI 4–11) vs 13 (95% CI 11–15)%; P=0.004] were significantly different between non-responders and Rs. The areas under the receiver operating characteristic curves of SVi and SVV for predicting fluid responsiveness were 0.88 (95% CI 0.71–0.97) and 0.81 (95% CI 0.66–0.96), for a cut-off value of 29 ml m−2 (grey zone 27–29 ml m−2) and 10% (grey zone 9–15%), respectively. Conclusions The results of this study show that SVi and SVV non-invasively measured by bioreactance are predictive of fluid responsiveness in sedated and mechanically ventilated children after surgery.

Epidemiological data regarding the frequency of the different causes of coma and their evolution over time in the ICU are scarce [1–4]. In the 1970s, Plum and Posner [2] described the causes of 500 successive cases of coma. However, since then no specific study focusing on the causes of coma and their evolution over time has been published although the ICU management of brain injuries has progressed tremendously. Some data are available from prospective and retrospective studies assessing coma outcome [3–8], but the different causes of coma were excluded in these studies. These studies, therefore, do not provide a global description of the causes of coma and their evolution. The aim of this study was to describe the causes of coma and their evolution over an 8-year time period in a medical ICU. From January 2001 to December 2008, we retrospectively identified patients who presented with coma in the first 24 h of ICU admission, defined as a Glasgow Coma Scale below 8 in the absence of sedative drugs, and we retrieved their demographic data (supplementary Table). For statistical purposes, four time periods of 2 years each were defined. A total of 2,189 out of 4,482 patients were evaluated. Baseline characteristics of the patients can be found in the supplementary Table. Detailed causes of coma, initial Glasgow Coma Scale and ICU survival are shown Table 1. The frequency of anoxo-ischemic encephalopathy and shock of any origin increased as the causes of coma over the 8-year time period is shown in Table 2. At the same time, the frequency of the other causes of coma remained stable. Among the 2,189 comatose patients, 1,139 (52%) survived to ICU discharge (Table 1). Survival rates according to each cause of coma are given in the Table 1. To our knowledge, this is the largest existing cohort that focused on the causes of coma and their evolution. The study population was comparable in age, sex ratio, and the Glasgow Coma Scale score to previously reported populations of comatose patients as in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) cohort. SUPPORT, the largest previously available cohort of 596 non-traumatic comatose patients, studied factors such as high risk of death and severe disability [1–8]. However, the SUPPORT cohort excluded drug intoxication and metabolic causes of coma [4]. Plum and Posner [2] found that the most common causes of coma were drug poisons (30%), cerebral hemorrhage including intracerebral, epidural, and subdural hemorrhages (15%), and brainstem infarction (8%). Cardiac arrest represented only 2% in the Plum and Posner cohort. This discrepancy could be somewhat explained by the fact that the Plum and Posner’s study was performed in a neurological ICU, whereas our study was performed in a general medical ICU. Moreover, our study was subject to regular updates of the guidelines for cardiac arrest resuscitation which has improved immediate survival over the last 30 years. This hypothesis is corroborated by the findings of the other previous reports [4–8]. The reason for the Electronic supplementary material The online version of this article (doi:10.1007/s00415-011-6388-z) contains supplementary material, which is available to authorized users.

Introduction Ventilator-associated pneumonia (VAP) is frequent in Intensive Care Unit (ICU) patients. In the specific case of patients treated with Veno-Arterial Extracorporeal Membrane Oxygenation Support (VA-ECMO), VAP treatment failures (VAP-TF) have been incompletely investigated. Methods To investigate the risk factors of treatment failure (VAP-TF) in a large cohort of ICU patients treated with VA-ECMO, we conducted a retrospective study in a Surgical ICU about patients assisted with VA-ECMO between January 1, 2013, and December 31, 2014. Diagnosis of VAP was confirmed by a positive quantitative culture of a respiratory sample. VAP-TF was defined as composite of death attributable to pneumonia and relapse within 28 days of the first episode. Results In total, 152 patients underwent ECMO support for > 48h. During the VA-ECMO support, 85 (55.9%) patients developed a VAP, for a rate of 60.6 per 1000 ECMO days. The main pathogens identified were Pseudomonas aeruginosa and Enterobacteriaceae. VAP-TF occurred in 37.2% of patients and was associated with an increased 28-day mortality (Hazard Ratio 3.05 [1.66; 5.63], P

Background Data are scarce about the prognosis of heart allograft antibody-mediated rejection (AMR) with hemodynamic involvement. Purpose To evaluate the prognosis of cardiogenic shock due to antibody mediated rejection. Methods We performed a retrospective, single center, observational study. We included all consecutive patients with (1) definite diagnosis of antibody-mediated (AMR) rejection treated at our center and (2) cardiogenic shock due to AMR. We analyzed survival after AMR and causes of death. Patients alive after AMR were followed to analyze recurrences of AMR, graft function and cardiac allograft vasculopathy. Results Finally, 17 patients met inclusion criteria. Four patients were transplanted with MFI > 1000 preformed DSA. Median time between heart transplantation and AMR was 21.5 months (10–64 months). AMR was mostly due to high-level class II de novo DSA (76% of patients). Despite aggressive immunosuppressive therapies, in-hospital and 1-year mortality were respectively as high as 76 and 82%. All patients discharged from hospital normalized LVEF during follow-up. However, 2 patients were diagnosed with recurrent subclinical AMR: one died suddenly at home and the other presented rapidly progressive cardiac allograft vasculopathy ( Fig. 1 ). Conclusion Despite aggressive immunosuppressive therapies, prognosis after cardiogenic shock due to AMR is poor with 76% in-hospital mortality. However, follow-up of patients discharged from hospital revealed normalization of LVEF.

Thoracic bioreactance is a noninvasive and continuous method of cardiac output (CO) measurement that is being developed in adult patients. Very little information is available on thoracic bioreactance use in children.The aim of the study was to evaluate the ability of a bioreactance device (NICOM(®) ; Cheetah Medical, Tel Aviv, Israel) to estimate CO and to track changes in CO induced by volume expansion (VE) in children.Cardiac output values obtained using the NICOM(®) device (CONICOM ) and measured by trans-thoracic echocardiography (COTTE ) were compared in pediatric neurosurgical patients during the postoperative period.Seventy-three pairs of measurements of CO obtained in 30 children were available for analysis. The bias (lower and upper limits of agreement) between CONICOM and COTTE was -0.11 (-1.4 to 1.2) l·min(-1). The percentage error (PE) was 55%. The precision of the NICOM(®) device was 45%. A significant correlation was observed between the CO values obtained using the two methods (r = 0.89,0.001). The concordance percentage between changes in COTTE and CON icom induced by VE was 84% following exclusion of patients with changes in CO15% (n = 5).The PE observed is too large, and the limits of agreement too wide, to enable us to comment on the equivalence of the two techniques of CO measurements. However, the NICOM(®) device performs well in tracking changes in CO following VE.

Introduction Depuis 2004 les patients atteints d’une insuffisance cardiaque terminale decompensee beneficient d’une priorisation nationale dite de « Super urgence 1 » (SU1). Le benefice de la transplantation dans ce contexte d’urgence n’est pas evident et certaines equipes rapportent de bons resultats chez les patients transplantes au decours d’une rehabilitation sous assistance circulatoire de longue duree (ALD) implante de maniere programmee. En revanche, cette derniere attitude n’a pas ete etudiee dans le contexte de SU1. L’objectif de ce travail etait de comparer la survie des patients inscrit en SU1 beneficiant d’une transplantation d’emblee avec ceux n’ayant pas recu de greffon et ayant donc ete implantes d’une ALD en transition a la transplantation. Materiel et methodes Il s’agit d’une etude retrospective monocentrique incluant les patients inscrits sur la liste de transplantation en SU1 du 1 er janvier 2008 au 30 juin 2013. Le critere principal de jugement est la mortalite intra-hospitaliere. Le critere de jugement secondaire est la mortalite a 1 an. Les donnees sont exprimees en mediane (quartile a 25 % et 75 %) et en pourcentage. La comparaison entre les groupes est effectuee par les tests de Mann-Whitney et de Fischer. Resultats Au total, 227 patients ont ete inclus. Parmi ces patients, 162 ont beneficie d’une transplantation en SU, 33 patients ont ete implantes faute de greffon d’une ALD [22 assistances biventriculaires (BIV) et 11 assistances monoventriculaire gauches (LVAD)]. Enfin 16 patients sont decedes en liste de SU et 15 patients ont ete exclus de l’analyse du fait d’une transplantation en dehors de la SU. La comparaison entre le groupe transplantes en SU et ALD n’objectivait pas de difference d’âge [51 (40–59) vs 49 (40–59) ans, p = 0,82], d’incidence de recours a l’ECMO pre-operatoire (38 % vs 35 %, p = 1,0) et de gravite pre-operatoire [SOFA a 5 (4–6) vs 5 (4–6), p = 0,19]. Les mortalites intra-hospitalieres et a 1 an etaient significativement inferieures dans le groupe transplantes en SU par rapport au groupe ALD (23 % vs 55 %, p p p = 0,06). La mortalite des patients transplantes malgre un echec de SU etait de 20 %. Les patients sous ALD survivants a 1 an ont tous ete transplantes avec une survie posttransplantation a 1 an de la greffe de 100 % ( Fig. 1 ). Discussion La transplantation cardiaque en SU1 semble etre une bonne strategie pour les patients en insuffisance cardiaque terminale decompensee. En cas d’echec de SU, la decision d’implantation d’un ALD doit donner lieu a une reevaluation minutieuse, notamment en cas d’assistance de type BIV pour laquelle la mortalite liee a l’implantation est plus elevee.

Introduction Dans le cadre du syndrome de bas debit cardiaque (SDBC) post-cardiotomie, le recours a l’assistance circulatoire veino-arterielle peripherique (ECMO VAP) a fait la preuve de son efficacite et est largement utilise [1] . L’ECMO n’est pas denuee de risques notamment infectieux et thrombo-emboliques, et son explantation doit etre evaluee quotidiennement et realisee des que possible. Pour assurer le succes de cette explantation, les criteres de sevrage de l’ECMO sont bases sur des criteres exclusivement echocardiographiques [2] . Le monitorage de la l’oxymetrie cerebrale (rSO 2 ) par la technique de near-infrared spectroscopy (NIRS) est une technique validee permettant d’evaluer la perfusion tissulaire peripherique. Le but de notre travail etait d’evaluer : – l’evolution de la variation de rSO 2 au cours de la recuperation cardiaque sous ECMO ; – le benefice de ce monitorage dans la prediction de la reussite du sevrage de l’ECMO. Materiel et methodes Etude prospective observationnelle non interventionnelle realisee avec l’accord du comite d’ethique institutionnel et sans necessite de consentement eclaire, chez des patients presentant un SDBC post-cardiotomie ayant necessite l’implantation d’une ECMO VAP entre le 1 er mars et le 30 avril 2014. La rSO 2 etait monitoree en continu (INVOS®System, Somanetics, Etats-Unis) des l’implantation jusqu’au sevrage de l’ECMO VAP. Le potentiel de sevrage etait evalue quotidiennement et base sur l’echocardiographie. Les variations de rSO 2 (ΔrSO 2 ) entre le debit optimal d’assistance et le debit de sevrage a 2 L/min etaient monitorees. Resultats Quatorze patients âges de 65,0 [55,0 ; 74,5] ans ont ete inclus. Les types de chirurgie etaient : transplantation cardiaque [2] , assistance mono-ventriculaire gauche [1] , pontages coronaires ( n = 3), remplacement valvulaire ( n = 2), chirurgie combinee ( n = 4), et tube sus-coronaire ( n = 1). La duree d’assistance par ECMO etait de 8 [6 ; 9] jours. Les ΔrSO 2 au cours de l’epreuve de sevrage n’etaient pas differentes entre les patients sevrables ou non (–2,0 [–5,7 ; –2,0] % vs. –3,0 [–6,0 ; –0,5] % ; p = 0,98). Il n’existait pas de difference significative de ΔrSO 2 au cours des epreuves de sevrage quotidiennes. En revanche, les criteres echographiques (FEVG, TAPSE, onde S) etaient associes au succes de l’epreuve de sevrage. En analyse multivariee, les ΔrSO 2 pendant l’epreuve de sevrage etaient associees de facon independante aux variations de SpO 2 et a la fraction d’ejection du ventricule gauche. Discussion Dans cette etude pilote, les variations de rSO 2 observees au cours des epreuves de sevrage d’une ECMO VAP etaient associees aux variations de SpO 2 et de FEVG. Le monitorage par NIRS n’apportait pas d’information supplementaire quant a la sevrabilite de l’ECMO par rapport aux parametres precedemment rapportes dans la litterature.

Introduction L’arsenal therapeutique des patients victimes d’une pathologie coronarienne comprend une mono- ou une bitherapie anti agregante plaquettaire (AAP) [1] . Lorsqu’il est necessaire de proceder a une revascularisation chirurgicale, le maintien de ces traitements AAP est un facteur de risque reconnu de saignement peri operatoire. Le prasugrel et le ticagrelor (antagonistes du recepteur P2Y12) sont deux nouveaux AAP recemment mis a la disposition des cliniciens. Chez les patients subissant un pontage aorto-coronaire, le ticagrelor a montre un benefice en termes de mortalite sans augmentation du saignement peri-operatoire [2] , quand le prasugrel a ete associe avec une augmentation du saignement sans augmentation des besoins transfusionnels [3] . Le but de cette etude etait d’evaluer et de comparer le saignement peri-operatoire en fonction du traitement AAP prealable dans une cohorte de patients operes d’un pontage aorto-coronaire (PAC). Materiel et methodes Etude retrospective, observationnelle, monocentrique incluant tous les patients ayant beneficies d’une chirurgie isolee de PAC. Le critere de jugement principal etait le volume de saignement cumule a la 6e heure post-operatoire en fonction du traitement AAP. Les criteres de jugement secondaires etaient le recours a la transfusion de produits sanguins labiles, une reprise chirurgicale pour hemostase ou tamponnade dans les 24 premieres heures, les complications infectieuses (mediastinite, pneumopathie) et la mortalite a un mois. Resultats Entre le 1er decembre 2012 et le 31 novembre 2013, 344 patients ont beneficie d’une revascularisation chirurgicale coronaire. Les patients etaient des hommes dans 82 % des cas, âges de 66 (59–73) ans. La chirurgie etait realisee en urgence chez 72 patients (21 %). L’Euroscore II etait de 1,43 % (0,88–2,87). La mortalite etait de 4,65 %. Dans la cohorte totale, le saignement receuilli a la 6e heure post operatoire (H6) etait de 244 ± 211 mL, et de 427 ± 323 mL a j1. Il n’existait pas de difference significative de saignement a H6 entre les patients ayant recu aspirine seule (n = 181, 231 ± 194 mL), aspirine + clopidogrel (n = 106, 239 ± 217), aspirine + prasugrel (n = 13, 272 ± 140 mL) et aspirine + ticagrelor (n = 14, 373 ± 372 mL). De meme, il n’existait pas de difference significative de saignement a j1 entre les differents groupes. La quantite de culots globulaires (CG) ou de culots plaquettaires (CP) n’etait pas differente entre les groupes aspirine seule (0,17 ± 0,76), aspirine + clopidogrel (0,33 ± 1,0), et aspirine + prasugrel (0,16 ± 0,58). En revanche, les patients ayant recu aspirine + ticagrelor etaient significativement plus transfuses en CG (1,0 ± 1,88) (p = 0,0056) comme en CP (0,42 ± 0,75) (p = 0,0053). Discussion Dans cette cohorte de patients operes pour un PAC, l’administration d’aspirine et de ticagrelor etait associee a un recours plus important a une transfusion de produits sanguins labiles. L’administration de prasugrel ne semble associee a un risque hemorragique accru.

Identifiant de l'operation archeologique : Date de l'operation : 1991 (PR) Inventeur(s) : Vidal Charles Un projet d'autoroute entre Pamiers (Ariege) et Toulouse (Haute-Garonne) a necessite la mise en place d'une etude d'impact preliminaire afin d'evaluer la potentialite archeologique d'un secteur devant etre perturbe,a moyen terme, par des travaux autoroutiers. Cet etat des connaissances est lie, dans un premier temps, a l'etude de la bibliographie existante, de la geologie, de la toponymie ...

International audience; Objectives: Prone positioning and venovenous extracorporeal membrane oxygenation (ECMO) are both useful interventions in acute respiratory distress syndrome (ARDS). Combining the two therapies is feasible and safe, but the effectiveness is not known. Our objective was to evaluate the potential survival benefit of prone positioning in venovenous ECMO patients cannulated for COVID-19-related ARDS.Design: Retrospective analysis of a multicenter cohort.Patients: Patients on venovenous ECMO who tested positive for severe acute respiratory syndrome coronavirus 2 by reverse transcriptase polymerase chain reaction or with a diagnosis on chest CT were eligible.Interventions: None.Measurements and main results: All patients on venovenous ECMO for respiratory failure in whom prone position status while on ECMO and in-hospital mortality were known were included. Of 647 patients in 41 centers, 517 were included. Median age was 55 (47-61), 78% were male and 95% were proned before cannulation. After cannulation, 364 patients (70%) were proned and 153 (30%) remained in the supine position for the whole ECMO run. There were 194 (53%) and 92 (60%) deaths in the prone and the supine groups, respectively. Prone position on ECMO was independently associated with lower in-hospital mortality (odds ratio = 0.49 [0.29-0.84]; p = 0.010). In 153 propensity score-matched pairs, mortality rate was 49.7% in the prone position group versus 60.1% in the supine position group (p = 0.085). Considering only patients alive at decannulation, propensity-matched proned patients had a significantly lower mortality rate (22.4% vs 37.8%; p = 0.029) than nonproned patients.Conclusions: Prone position may be beneficial in patients supported by venovenous ECMO for COVID-19-related ARDS but more data are needed to draw definitive conclusions.

Background Despite expanding use, knowledge on extracorporeal membrane oxygenation support during the COVID-19 pandemic remains limited. The objective was to report characteristics, management, and outcomes of patients receiving extracorporeal membrane oxygenation with a diagnosis of COVID-19 in France and to identify pre-extracorporeal membrane oxygenation factors associated with in-hospital mortality. A hypothesis of similar mortality rates and risk factors for COVID-19 and non–COVID-19 patients on venovenous extracorporeal membrane oxygenation was made. Methods The Extracorporeal Membrane Oxygenation for Respiratory Failure and/or Heart failure related to Severe Acute Respiratory Syndrome-Coronavirus 2 (ECMOSARS) registry included COVID-19 patients supported by extracorporeal membrane oxygenation in France. This study analyzed patients included in this registry up to October 25, 2020, and supported by venovenous extracorporeal membrane oxygenation for respiratory failure with a minimum follow-up of 28 days after cannulation. The primary outcome was in-hospital mortality. Risk factors for in-hospital mortality were analyzed. Results Among 494 extracorporeal membrane oxygenation patients included in the registry, 429 were initially supported by venovenous extracorporeal membrane oxygenation and followed for at least 28 days. The median (interquartile range) age was 54 yr (46 to 60 yr), and 338 of 429 (79%) were men. Management before extracorporeal membrane oxygenation cannulation included prone positioning for 411 of 429 (96%), neuromuscular blockage for 419 of 427 (98%), and NO for 161 of 401 (40%). A total of 192 of 429 (45%) patients were cannulated by a mobile extracorporeal membrane oxygenation unit. In-hospital mortality was 219 of 429 (51%), with a median follow-up of 49 days (33 to 70 days). Among pre-extracorporeal membrane oxygenation modifiable exposure variables, neuromuscular blockage use (hazard ratio, 0.286; 95% CI, 0.101 to 0.81) and duration of ventilation (more than 7 days compared to less than 2 days; hazard ratio, 1.74; 95% CI, 1.07 to 2.83) were independently associated with in-hospital mortality. Both age (per 10-yr increase; hazard ratio, 1.27; 95% CI, 1.07 to 1.50) and total bilirubin at cannulation (6.0 mg/dl or more compared to less than 1.2 mg/dl; hazard ratio, 2.65; 95% CI, 1.09 to 6.5) were confounders significantly associated with in-hospital mortality. Conclusions In-hospital mortality was higher than recently reported, but nearly half of the patients survived. A high proportion of patients were cannulated by a mobile extracorporeal membrane oxygenation unit. Several factors associated with mortality were identified. Venovenous extracorporeal membrane oxygenation support should be considered early within the first week of mechanical ventilation initiation. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background: The prognosis of obese patients in intensive care is subject to debate. However, obesity is still considered a relative contraindication to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Therefore, we investigated the link between body mass index (BMI) and mortality in intensive care.Methods: In this retrospective and single-center study, all patients undergoing VA-ECMO between January 2014 and December 2019 were included. The primary outcome was mortality in intensive care unit.Results: Among the 150 patients included and according to the WHO’s definitions, 10 patients were underweight (BMI < 18.5), 62 were normal weight (BMI = 18.5-24.9), 34 were overweight (BMI = 25.0-29.9), 34 were class I obese (BMI = 30.0-34.9) and 10 were class II obese (BMI = 35.0-39.9). The mortality rate was 62% (underweight, 70%; normal, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariable logistic regression, BMI was not associated with ICU mortality (OR 0.991 [0.92 - 1.07], p = 0.8). Analysis by BMI class showed a more unfavorable trend in underweight patients (OR 3.58 [0.816-19.6], p = 0.11). There were no significant differences in incidences of nosocomial infection, bleeding and stroke among the different weight categories. Conclusion: BMI was not associated with mortality in our study. Obesity alone should not be an exclusion criterion for VA-ECMO. However, a more unfavorable trend appeared in underweight patients.; Introduction : Le pronostic du patient obèse en réanimation est sujet à débat. L’obésité reste cependant considérée comme une contre-indication relative à l’assistance circulatoire par membrane d’oxygénation extracorporelle veino-artérielle (ECMO VA) lors d’un choc cardiogénique réfractaire. Ainsi, nous avons étudié le lien entre l’indice de masse corporelle (IMC) et le devenir du patient en réanimation.Méthodes : Dans cette une étude rétrospective et monocentrique, tous les patients traités par ECMO VA de janvier 2014 à décembre 2019 étaient inclus. Le critère de jugement primaire était la mortalité en réanimation.Résultats : Parmi les 150 patients inclus et selon les définitions de l’OMS, 10 étaient insuffisants pondéraux (IMC < 18.5), 62 étaient normo-corpulents (IMC = 18.5-24.9), 34 étaient en surpoids (IMC = 25.0-29.9), 34 étaient obèses modérés (IMC = 30.0-34.9) et 10 étaient obèses sévères (IMC = 35.0-39.9). Le taux de mortalité en réanimation était de 62% (insuffisance pondérale, 70% ; normo-corpulence, 53% ; surpoids, 65% ; obésité modérée, 71% ; obésité sévère, 70% ; p = 0.94). Après analyses multivariées, l’IMC n’était pas associé à la mortalité en réanimation (OR 0.991 [0.92-1.07], p = 0.8). L’analyse par classe retrouvait une tendance plus défavorable chez les patients insuffisants pondéraux (OR 3.58 [0.816-19.6], p = 0.11). Il n’y avait pas de différence de taux d’infections nosocomiales, de saignements et d’AVC selon les classes pondérales.Conclusion : L’IMC n’était pas associé à la mortalité dans notre étude. L’obésité sévère seule ne devrait pas exclure l’implantation d’une ECMO VA. Cependant, une tendance plus défavorable se dessinait chez les patients insuffisants pondéraux.

Background : Pulmonary contusions in thoracic trauma patients can lead to acute respiratory distress syndrome (ARDS) requiring the use of respiratory support such as vein veinous extracorporeal membrane oxygenation (ECMO VV). The objective of this work is to make a descriptive analysis of patients assisted by ECMO VV for traumatic respiratory failure and to compare their survival compared to non-trauma patients.Method : This is a retrospective study including all the patients hospitalized in multipurpose intensive care at the Félix Guyon CHU in Reunion Island over the period 2011-2018 who benefited from a VV ECMO following a thoracic trauma complicated by ARDS.Results : During the inclusion period, 124 VV ECMOs were implanted, including 9 VV ECMOs for ARDS following thoracic trauma. In the group of trauma patients: the initial traumas were road accidents in 55.6% of cases, weaning was carried out in 88% of patients, the median age was 45 years (19-55), the simplified severity index 2 was not significantly different (42 vs 48 p = 0.96), the in-hospital mortality was significantly lower (11.1% vs 48.7% p = 0.037), the incidence of bleeding complications were not significantly less (11.1% vs 46.1% p = 0.07) and the incidence of pneumonia was significantly higher (88.9% vs 29.8% p = 0.001).Conclusion : ECMO VV is an effective respiratory support device in patients with ARDS following severe chest trauma and is associated with few bleeding complications.; Introduction : Les contusions pulmonaires chez les traumatisés thoraciques peuvent entrainer un syndrome de détresse respiratoire aigu (SDRA) nécessitant le recours à une assistance respiratoire de type membrane d’oxygénation extracorporelle veino-veineuse (ECMO VV). L'objectif de ce travail est de faire une analyse descriptive des patients assistés par l’ECMO VV pour défaillance respiratoire d’origine traumatique et de comparer leur survie par rapport aux patients non traumatisés.Méthode : Il s’agit d’une étude rétrospective incluant tous les patients hospitalisés en réanimation polyvalente du CHU Félix Guyon de la Réunion sur la période 2011-2018 ayant bénéficié d’une ECMO VV dans les suites d’un traumatisme thoracique compliqué d’un SDRA.Résultats : Durant la période d’inclusion, 124 ECMO VV ont été implantées dont 9 ECMO VV pour SDRA dans les suites d’un traumatisme thoracique. Dans le groupe de patients traumatisés : les traumatismes initiaux étaient des accidents de la voie publique dans 55,6% des cas, le sevrage a pu être effectué chez 88% des patients, l’âge médian était de 45ans (19-55), l’indice de gravité simplifié 2 n’était pas significativement différent (42 vs 48 p=0,96), la mortalité intra hospitalière était significativement inférieure (11,1% contre 48,7% p=0,037), l’incidence de complications hémorragiques n’était pas significativement moindre (11,1% vs 46,1% p=0,07) et l’incidence des pneumonies était significativement supérieure (88,9% vs 29,8% p=0,001).Conclusion : L’ECMO VV est un dispositif de suppléance respiratoire efficace chez les patients présentant un SDRA dans les suites d’un traumatisme thoracique grave et est associé à peu de complications hémorragiques.

Introduction: Immunosuppressive therapy used after heart transplantation predispose recipients to post-operative infection and is associated with potential worse outcomes. The objective of this study was to investigate the epidemiology and the risk factors of post-operative infection in recipients beneficing of heart transplantation. Material and Methods: We investigated all patients underwent heart transplantation between January 2014 and December 2015. All the post-operative infections occurring during hospitalization were recorded. The "infected" and "non-infected" patients were compared by Wilcoxon or Fisher tests. A test of Log Rank and a Cox model was used for univariate and multivariate analysis.Results: At all, 175 recipients were retrospectively investigated and 233 post-operative infections occurred in 119 patients (68% of the recipients). Main infections were pneumoniae (89) and infections of inguinal cannulation site (60) after veno-arterial Extracorporeal Membrane Oxygenation (VA ECMO). In multivariate analysis, risk factors of post-operative infection were VA ECMO before transplantation (OR : 1,16 [IC95 :1,00-1,35], p=0,04) and after transplantation (OR : 1,28 [IC95 :1,10-1,48], p < 0,01), blood transfusion > 2 units packed cell (OR : 1,21 [IC95: 1.05-1.39], p 2 culots globulaires (CGR) en post-opératoire (OR : 1,21 [IC95: 1.05-1.39], p