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In relatives of patients dying in intensive care units (ICUs), inadequate team support can increase the prevalence of prolonged grief and other psychological harm. We aimed to evaluate whether a proactive communication and support intervention would improve relatives' outcomes.We undertook a prospective, multicentre, cluster randomised controlled trial in 34 ICUs in France, to compare standard care with a physician-driven, nurse-aided, three-step support strategy for families throughout the dying process, following a decision to withdraw or withhold life support. Inclusion criteria were relatives of patients older than 18 years with an ICU length of stay 2 days or longer. Participating ICUs were randomly assigned (1:1 ratio) into an intervention cluster and a control cluster. The randomisation scheme was generated centrally by a statistician not otherwise involved in the study, using permutation blocks of non-released size. In the intervention group, three meetings were held with relatives: a family conference to prepare the relatives for the imminent death, an ICU-room visit to provide active support, and a meeting after the patient's death to offer condolences and closure. ICUs randomly assigned to the control group applied their best standard of care in terms of support and communication with relatives of dying patients. The primary endpoint was the proportion of relatives with prolonged grief (measured with PG-13, score ≥30) 6 months after the death. Analysis was by intention to treat, with the bereaved relatives as the unit of observation. The study is registered with ClinicalTrials.gov, NCT02955992.Between Feb 23, 2017, and Oct 8, 2019, we enrolled 484 relatives of ICU patients to the intervention group and 391 to the control group. 379 (78%) relatives in the intervention group and 309 (79%) in the control group completed the 6-month interview to measure the primary endpoint. The intervention significantly reduced the number of relatives with prolonged grief symptoms (66 [21%] vs 57 [15%]; p=0·035) and the median PG-13 score was significantly lower in the intervention group than in the control group (19 [IQR 14-26] vs 21 [15-29], mean difference 2·5, 95% CI 1·04-3·95).Among relatives of patients dying in the ICU, a physician-driven, nurse-aided, three-step support strategy significantly reduced prolonged grief symptoms.French Ministry of Health.

Natraemia is often abnormal in critically ill patients and may change rapidly during renal replacement therapy (RRT). This database study in a single intensive care unit (ICU) evaluated natraemia before and after the first RRT session for acute kidney injury. Of 252 patients who required RRT in 2018–2020, 215 were included. Prevalences were 53.9% for hyponatraemia (≤ 135 mmol/L) and 3.7% for hypernatraemia (> 145 mmol/L). Dialysate sodium was ≥ 145 mmol/L in 83% of patients. Median dialysis sodium gradient was 12 mmol/L, with a value above 16 mmol/L in 25% of patients. Median natraemia increased from 135 before to 140 mmol/L after RRT, the median hourly increase being faster than recommended, at 1.0 mmol/L [0.2–1.7]. By multivariate analysis, the only variable significantly associated with the RRT-induced natraemia change was the dialysis sodium gradient [odds ratio, 1.66; 95% confidence interval 1.39–2.10]. Pearson’s correlation coefficient between the gradient and the natraemia change was 0.57. When performing RRT in ICU patients, in addition to the haemodynamic considerations put forward in recommendations, the dialysis sodium gradient deserves careful attention in order to control natraemia variations. Studies to devise a formula for predicting natraemia variations might prove helpful to confirm our results.

Background To evaluate the association between ventilator type and hospital mortality in patients with acute respiratory distress syndrome (ARDS) related to COVID-19 (SARS-CoV2 infection), a single-center prospective observational study in France. Results We prospectively included consecutive adults admitted to the intensive care unit (ICU) of a university-affiliated tertiary hospital for ARDS related to proven COVID-19, between March 2020 and July 2021. All patients were intubated. We compared two patient groups defined by whether an ICU ventilator or a less sophisticated ventilator such as a sophisticated turbine-based transport ventilator was used. Kaplan–Meier survival curves were plotted. Cox multivariate regression was performed to identify associations between patient characteristics and hospital mortality. We included 189 patients (140 [74.1%] men) with a median age of 65 years [IQR, 55–73], of whom 61 (32.3%) died before hospital discharge. By multivariate analysis, factors associated with in-hospital mortality were age ≥ 70 years (HR, 2.11; 95% CI, 1.24–3.59; P = 0.006), immunodeficiency (HR, 2.43; 95% CI, 1.16–5.09; P = 0.02) and serum creatinine ≥ 100 µmol/L (HR, 3.01; 95% CI, 1.77–5.10; P P = 0.39) nor with a longer ICU stay (24 [IQR, 14–40] vs. 27 [15–44] days, respectively; P = 0.44). Conclusions In ventilated patients with ARDS due to COVID-19, management in transient ICU equipped with non-ICU sophisticated turbine-based ventilators was not associated with worse outcomes compared to standard ICU, equipped with ICU ventilators. Although our study design is not powered to demonstrate any difference in outcome, our results after adjustment do not suggest any signal of harm when using these transport type ventilators as an alternative to ICU ventilators during COVID-19 surge.

Neutropenic enterocolitis occurs in about 5.3% of patients hospitalized for hematologic malignancies receiving chemotherapy. Data from critically ill patients with neutropenic enterocolitis are scarce. Our objectives were to describe the population of patients with neutropenic enterocolitis admitted to an ICU and to investigate the risk factors of invasive fungal disease.A multicentric retrospective cohort study between January 2010 and August 2017.Six French ICUs members of the Groupe de Recherche Respiratoire en Onco-Hématologie research network.Adult neutropenic patients hospitalized in the ICU with a diagnosis of enteritis and/or colitis. Patients with differential diagnosis (Clostridium difficile colitis, viral colitis, inflammatory enterocolitis, mesenteric ischemia, radiation-induced gastrointestinal toxicity, and Graft vs Host Disease) were excluded.None.We included 134 patients (median Sequential Organ Failure Assessment 10 [8-12]), with 38.8% hospital mortality and 32.1% ICU mortality rates. The main underlying malignancies were acute leukemia (n = 65, 48.5%), lymphoma (n = 49, 36.6%), solid tumor (n = 14, 10.4%), and myeloma (n = 4, 3.0%). Patients were neutropenic during a median of 14 days (9-22 d). Infection was documented in 81 patients (60.4%), including an isolated bacterial infection in 64 patients (47.8%), an isolated fungal infection in nine patients (6.7%), and a coinfection with both pathogens in eight patients (5.0%). Radiologically assessed enteritis (odds ratio, 2.60; 95% CI, 1.32-7.56; p = 0.015) and HIV infection (odds ratio, 2.03; 95% CI, 1.21-3.31; p = 0.016) were independently associated with invasive fungal disease.The rate of invasive fungal disease reaches 20% in patients with neutropenic enterocolitis when enteritis is considered. To avoid treatment delay, antifungal therapy might be systematically discussed in ICU patients admitted for neutropenic enterocolitis with radiologically assessed enteritis.

Background: Lumbar puncture is among the investigations used to determine the aetiology and prognosis of cardiac arrest, despite a dearth of data on its performance. We aimed to assess the diagnostic and prognostic performance of lumbar puncture after cardiac arrest. Methods: We retrospectively studied data from prospectively established databases of consecutive patients who were admitted to two French ICUs in 2007-2016 with sustained return of spontaneous circulation (ROSC) after cardiac arrest and who underwent lumbar puncture as an aetiological investigation. Results: Of 1984 patients with sustained ROSC, 65 (3.3%) underwent lumbar puncture and were included. Lumbar puncture identified a neurological cause of cardiac arrest in 6/65 (9%) patients, including 5 with neurologic prodromal symptoms before cardiac arrest and 4 with the lumbar puncture done post-mortem. Lumbar puncture performed before death showed nonspecific cerebrospinal fluid abnormalities in 37/53 (69.8%) patients. By univariate analysis, factors significantly associated with cerebrospinal fluid abnormalities were shorter no-flow time (0 min [0-3] versus 4 min [2-10], p=0.004) and post-resuscitation shock (26 [70%] versus 5 [31%], pp=0.06). Conclusions: Lumbar puncture, although rarely performed, can contribute to the aetiological diagnosis of cardiac arrest. As a second-line investigation, it identified the cause in 9% of our patients. Nonspecific cerebrospinal fluid abnormalities are common after cardiac arrest, perhaps due to blood-brain barrier disruption, and may carry prognostic significance.

Purpose Few outcome data are available about morbidity associated with endotracheal intubation modalities in critically ill patients with convulsive status epilepticus. We compared etomidate versus sodium thiopental for emergency rapid sequence intubation in patients with out-of-hospital convulsive status epilepticus. Methods Patients admitted to our intensive care unit in 2006–2015 were studied retrospectively. The main outcome measure was seizure and/or status epilepticus recurrence within 12 h after rapid sequence intubation. Results We included 97 patients (60% male; median age, 59 years [IQR, 48–70]). Median time from seizure onset to first antiepileptic drug was 60 min [IQR, 35–90]. Reasons for intubation were coma in 95 (98%), acute respiratory distress in 18 (19%), refractory convulsive status epilepticus in 9 (9%), and shock in 6 (6%) patients; 50 (52%) patients had more than one reason. The hypnotic drugs used were etomidate in 54 (56%) and sodium thiopental in 43 (44%) patients. Seizure and/or status epilepticus recurred in 13 (56%) patients in the etomidate group and 11 patients (44%) in the sodium thiopental group (adjusted common odds ratio [aOR], 0.98; 95%CI, 0.36–2.63; P = 0.97). The two groups were not significantly different for proportions of patients with hemodynamic instability after intubation (aOR, 0.60; 95%CI, 0.23–1.58; P = 0.30) or with difficult endotracheal intubation (OR, 1.28; 95% CI 0.23 to 7.21; P=0.77). Conclusions Our findings argue against a difference in seizure and/or status epilepticus recurrences rates between critically ill patients with convulsive status epilepticus given etomidate vs. sodium thiopental as the induction agent for emergency intubation.

International audience; PURPOSE: The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives. METHODS: This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3~months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff. RESULTS: We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3~months were not significantly different between groups (31.9~±~18.1 versus 30.5~±~16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p~=~0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group. CONCLUSIONS: Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01818895.

Background: Cuff leak test was developed to predict the occurrence of post-extubation stridor (PES). This study evaluated the diagnostic performance of this test in unselected critically ill patients. Methods: Multicenter prospective study including unselected ventilated patients at the time of their first planned extubation. The diagnostic performance of 4 different cuff leak tests was assessed. Results: Post-extubation stridor occurred in 34 (9.4%) of 362 included patients. Compared to patients without PES, patients with PES required more frequently reintubation (6 [17.6%] vs 26 [7.9%], P = .041), prolonged duration of ventilation (6 [3-13] vs 5 [2-9] days, P = .029), and longer intensive care unit (ICU) stay (12 [6-17.5] vs 7.5 [4-13] days, P = .018). However, ICU mortality was similar in both groups (1 [2.9%] vs 23 [7.0%], P = .61). The 4 cuff leak tests display poor diagnostic accuracy: sensitivities ranging from 27% to 46%, specificities from 70% to 88%, positive predictive values from 14% to 19%, and negative predictive values from 92% to 93%. Conclusion: Post-extubation stridor occurs in less than 10% of unselected critically ill patients. The several cuff leak tests display limited diagnostic performance for the detection of PES. Given the high rate of false positives, routine cuff leak test may expose to undue prolonged mechanical ventilation.

Convulsive status epilepticus often results in permanent neurologic impairment. We evaluated the effect of induced hypothermia on neurologic outcomes in patients with convulsive status epilepticus.In a multicenter trial, we randomly assigned 270 critically ill patients with convulsive status epilepticus who were receiving mechanical ventilation to hypothermia (32 to 34°C for 24 hours) in addition to standard care or to standard care alone; 268 patients were included in the analysis. The primary outcome was a good functional outcome at 90 days, defined as a Glasgow Outcome Scale (GOS) score of 5 (range, 1 to 5, with 1 representing death and 5 representing no or minimal neurologic deficit). The main secondary outcomes were mortality at 90 days, progression to electroencephalographically (EEG) confirmed status epilepticus, refractory status epilepticus on day 1, "super-refractory" status epilepticus (resistant to general anesthesia), and functional sequelae on day 90.A GOS score of 5 occurred in 67 of 138 patients (49%) in the hypothermia group and in 56 of 130 (43%) in the control group (adjusted common odds ratio, 1.22; 95% confidence interval [CI], 0.75 to 1.99; P=0.43). The rate of progression to EEG-confirmed status epilepticus on the first day was lower in the hypothermia group than in the control group (11% vs. 22%; odds ratio, 0.40; 95% CI, 0.20 to 0.79; P=0.009), but there were no significant differences between groups in the other secondary outcomes. Adverse events were more frequent in the hypothermia group than in the control group.In this trial, induced hypothermia added to standard care was not associated with significantly better 90-day outcomes than standard care alone in patients with convulsive status epilepticus. (Funded by the French Ministry of Health; HYBERNATUS ClinicalTrials.gov number, NCT01359332 .).

Background Obesity prevalence has dramatically increased over recent years and is associated with cardiovascular diseases, but data are lacking on its prognostic impact in out-of-hospital cardiac arrest (OHCA) patients. Methods Data of all consecutive OHCA patients admitted in two cardiac arrest centers from Paris and suburbs between 2005 and 2012 were prospectively collected. Patients treated by therapeutic hypothermia (TH) were included in the analysis. Logistic and Cox regression analyses were used to quantify the association between body mass index (BMI) at hospital admission and day-30 and 1-year mortality respectively. Results 818 patients were included in the study (median age 60.9 [50.8–72.7] year, 70.2% male). Obese patients (BMI>30kgm −2 ) were older, more frequently male and evidenced more frequently cardiovascular risk factors than normally (18.5 −2 ) or overweight patients (25 −2 ). Post-resuscitation shock and therapeutic hypothermia failure were more frequent in obese patients. Overall mortality at day-30 and one-year was 63.8 and 67.2%, respectively. After multivariate adjustment, BMI>30kgm −2 was independently associated with day-30 mortality (Odds ratio [OR] in comparison with normally weight patients 2.45; 95% confidence interval [95%CI: 1.32–4.56; p Conclusion In the present study, obesity was independently associated with day-30 mortality in successfully resuscitated ICU TH OHCA patients. Further studies are needed to understand the mechanisms that underpin this finding.

Bereavement research has helped to improve end-of-life practices in the ICU. However, few studies have explored bereaved relatives experience of research participation in this context. We aimed to explore the experience of bereaved relatives’ participation in the ARREVE study which included three telephone follow-up calls to complete several quantitative tools. Volunteer relatives who participated in the 12-month follow-up call completed a questionnaire about research participation that included ten open-ended questions so that respondents could use their own words and thoughts. These open-ended questions were analyzed using qualitative analysis that examines themes within the data. 175/311 relatives completed the questionnaire. Three themes were derived from the thematic analysis: (1) struggling: reactivation of emotional distress associated with the ICU experience and the loss is frequent, specifically during the 1st follow-up call. (2) Resilience: as time goes by, research participation becomes increasingly positive. The calls are a help both in giving meaning to the relatives’ experience and in accepting the loss. (3) Recognition: research calls can compensate for the absence of support during bereavement. Although some emotional difficulties must be acknowledged, bereavement research is overall associated with benefits, by facilitating emotional adjustments, meaning-making and resilience. Lack of support and social isolation during bereavement are frequent experiences, revealing that support strategies for bereaved relatives should be developed after the loss of a loved one in the ICU.

International audience; Background: Stenotrophomonas maltophilia (SM) is increasingly identified in intensive care unit (ICU). This study aim to identify risk factors for SM ventilator-associated pneumonia (VAP) and whether it affects ICU mortality METHODS: Two nested matched case-control studies were performed based in OUTCOMEREA database. The first episodes of SM-VAP patients were matched with two different control groups: VAP due to other micro-organisms (VAP-other) and Pseudomonas aeruginosa VAP (Pyo-VAP). Matching criteria were the hospital, the SAPS II, and the previous duration of mechanical ventilation (MV).Results: Of the 102 SM-VAP patients (6.2% of all VAP patients), 92 were matched with 375 controls for the SM-VAP/other-VAP matching and 84 with 237 controls for the SM-VAP/Pyo-VAP matching. SM-VAP risk factors were an exposition to ureido/carboxypenicillin or carbapenem during the week before VAP, and respiratory and coagulation components of SOFA score upper to 2 before VAP. SM-VAP received early adequate therapy in 70 cases (68.6%). Risk factors for Day-30 were age (OR = 1.03; p < 0.01) and Chronic heart failure (OR = 3.15; p < 0.01). Adequate treatment, either monotherapy or combination of antimicrobials, did not modify mortality. There was no difference in 30-day mortality, but 60-day mortality was higher in patients with SM-VAP compared to Other-VAP (P = 0.056).Conclusions: In a large series, independent risk factors for the SM-VAP were ureido/carboxypenicillin or carbapenem exposure the week before VAP, and respiratory and coagulation components of the SOFA score > 2 before VAP. Mortality risk factors of SM-VAP were age and chronic heart failure. Adequate treatment did not improve SM-VAP prognosis.

International audience; Objectives: To describe the epidemiology and prognostic impact of pneumonia in acute ischemic stroke patients requiring invasive mechanical ventilation. Methods: Retrospective analysis from a prospective multicenter cohort study of critically ill patients with acute ischemic stroke requiring invasive mechanical ventilation at admission. Impact of pneumonia was investigated using Cox regression for 1-year mortality, and competing risk survival models for ICU mortality censored at 30-days. Results: We included 195 patients. Stroke was supratentorial in 62% and 64% of patients had a Glasgow coma scale score \textless8 on admission. Mortality at day-30 and 1 year were 56%, and 70%, respectively. Post-stroke pneumonia was identified in 78 (40%) patients, of which 46/78 (59%) episodes were present at ICU admission. Post-stroke pneumonia was associated with an increase in 1-year mortality (adjusted HR 1.49, 95% CI [1.01-2.20]). Post-stroke pneumonia was not associated with ICU mortality but was associated with a 1.6-fold increase in ICU length of stay (CSHR 0.62 [0.39-0.99], p = 0.06). Conclusions: In ischemic stroke patients requiring invasive ventilation, pneumonia occurred in 40% of cases and was associated with a 49% increase in 1-year mortality. Post-stroke pneumonia did not impact day-30 mortality but increased ICU length of stay. (C) 2019 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

International audience; Purpose : Relatives of intensive care unit (ICU) patients suffer emotional distress that impairs their ability to acquire the information they need from the staff. We sought to evaluate whether providing relatives with a list of important questions was associated with better comprehension on day 5.Methods : Randomized, parallel-group trial. Relatives of mechanically ventilated patients were included from 14 hospitals belonging to the FAMIREA study group in France. A validated list of 21 questions was handed to the relatives immediately after randomization. The primary endpoint was comprehension on day 5. Secondary endpoints were satisfaction (Critical Care Family Needs Inventory, CCFNI) and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale, HADS).Results : Of 394 randomized relatives, 302 underwent the day-5 assessment of all outcomes. Day-5 family comprehension was adequate in 68 (44.2%) and 75 (50.7%) intervention and control group relatives (P = 0.30), respectively. Over the first five ICU days, median number of family–staff meetings/patient was 6 [3–9], median total meeting time was 72.5 [35–110] min, and relatives asked a median of 20 [8–33] questions including 11 [6–13] from the list, with no between-group difference. Satisfaction and anxiety/depression symptoms were not significantly different between groups. The only variable significantly associated with better day-5 comprehension by multivariable analysis was a higher total number of questions asked before day 5.Conclusions : Providing relatives with a list of questions did not improve day-5 comprehension, secondary endpoints, or information time. Further research is needed to help families obtain the information they need.

While S-100B protein and Neuron-Specific Enolase (NSE) dosages have been extensively investigated for neurological prognostication after cardiac arrest (CA), there is no data about their ability to detect a cerebrovascular cause of CA. We assessed the utility of plasma S-100B protein and NSE measurements for early diagnosis of primary neurological cause in resuscitated CA patients.Case control study based on two prospectively acquired CA databases. Patients with a primary cerebrovascular etiology were compared with randomly selected CA of non-neurological cause. S-100B protein and NSE were measured at ICU admission in all patients.CA was due to a cerebrovascular etiology in 18 patients (subarachnoid hemorrhage, n = 15; ischemic stroke, n = 3), with an ICU mortality of 100%. Comparative group was constituted with 66 patients (cardiac etiology n = 45, respiratory etiology n = 21), with an ICU mortality of 71%. Admission S-100B protein concentration was 2.0 [0.63-7.15] μg/L in the cerebrovascular group and 0.45 [0.24-1.95] in the non-cerebrovascular group (p 0.001). In contrast, NSE concentration was similar in cerebrovascular and non-cerebrovascular etiologies (35 [25-103] μg/L vs. 27 [19-47] respectively, p = 0.16). Area under ROC curves for S-100B protein and NSE to predict cerebrovascular cause of CA was 0.75 [95% CI: 0.64-0.87] and 0.61 [95% CI: 0.45-0.76], respectively.Even if S-100B protein dosage performs slightly better than NSE, early dosages of these biomarkers are poorly predictive of a cerebrovascular etiology of CA. Our results suggest that early measurement of brain biomarkers should not be recommended to tailor the imaging strategy employed to investigate the CA cause.

Aim Low survival rate was previously described after cardiac arrest in cancer patients and may challenge the appropriateness of intensive care unit (ICU) admission after return of spontaneous circulation (ROSC). Objectives of this study were to report outcome and characteristics of cancer patients admitted to the ICU after cardiac arrest. Methods A retrospective chart review in seven medical ICUs in France, in 2002–2012. We studied consecutive patients with malignancies admitted after out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). Results Of 133 included patients of whom 61% had solid tumors, 48 (36%) experienced OHCA and 85 (64%) IHCA. Cardiac arrest was related to the malignancy or its treatment in 47% of patients. Therapeutic hypothermia was used in 51 (41%) patients. The ICU mortality rate was 98/133 (74%). Main causes of ICU death were refractory shock or multiple organ failure ( n =64, 48%) and neurological injury ( n =27, 20%); 42 (32%) patients died in ICU after treatment-limitation decisions. Twenty-four (18%) patients were discharged alive from the hospital. Overall 6-month survival rate was 14% (18/133, 95% confidence interval, 8–21%). Survival rates at ICU discharge and after 6 months did not differ significantly across type of malignancy or between the OHCA and IHCA groups, and neither were they significantly different from those in matched controls who had cardiac arrest but no malignancy. Conclusions Even if low, the 6-month survival rate of 14% observed in cancer patients admitted to the ICU after cardiac arrest and ROSC may support the admission of these patients to the ICU and may warrant an initial full-code ICU management.

SummaryBackground Among patients with thrombotic microangiopathies, acute kidney injury (AKI) is the hallmark of hemolytic uremic syndrome (HUS) and is largely underestimated in patients with thrombotic thrombocytopenic purpura (TTP). Objective We sought to report AKI features and outcomes in patients with TTP. Methods We conducted a retrospective study of 92 patients with TTP assessed by low ADAMTS13 activity (

Systemic capillary-leak syndrome is a very rare cause of recurrent hypovolemic shock. Few data are available on its clinical manifestations, laboratory findings, and outcomes of those patients requiring ICU admission. This study was undertaken to describe the clinical pictures and ICU management of severe systemic capillary-leak syndrome episodes.This multicenter retrospective analysis concerned patients entered in the European Clarkson's disease (EurêClark) Registry and admitted to ICUs between May 1992 and February 2016.Fifty-nine attacks occurring in 37 patients (male-to-female sex ratio, 1.05; mean ± SD age, 51 ± 11.4 yr) were included. Among 34 patients (91.9%) with monoclonal immunoglobulin G gammopathy, 20 (58.8%) had kappa light chains. ICU-admission hemoglobin and proteinemia were respectively median (interquartile range) 20.2 g/dL (17.9-22 g/dL) and 50 g/L (36.5-58.5 g/L). IV immunoglobulins were infused (IV immunoglobulin) during 15 episodes (25.4%). A compartment syndrome developed during 12 episodes (20.3%). Eleven (18.6%) in-ICU deaths occurred. Bivariable analyses (the 37 patients' last episodes) retained Sequential Organ-Failure Assessment score greater than 10 (odds ratio, 12.9 [95% CI, 1.2-140]; p = 0.04) and cumulated fluid-therapy volume greater than 10.7 L (odds ratio, 16.8 [1.6-180]; p = 0.02) as independent predictors of hospital mortality.We described the largest cohort of severe systemic capillary-leak syndrome flares requiring ICU admission. High-volume fluid therapy was independently associated with poorer outcomes. IV immunoglobulin use was not associated with improved survival; hence, their use should be considered prudently and needs further evaluation in future studies.

International audience; Correction to: Intensive Care Med (2017) DOI 10.1007/s00134-017-4891-0.

International audience; Background: Monoclonal gammopathy-associated systemic capillary-leak syndrome, also known as Clarkson disease, is a rare condition characterized by recurrent life-threatening episodes of capillary hyperpermeability in the context of a monoclonal gammopathy. This study was conducted to better describe the clinical characteristics, natural history, and long-term outcome of monoclonal gammopathy-associated systemic capillary-leak syndrome.Methods: We conducted a cohort analysis of all patients included in the European Clarkson disease (EurêClark) registry between January 1997 and March 2016. From diagnosis to last follow-up, studied outcomes (eg, the frequency and severity of attacks, death, and evolution toward multiple myeloma) and the type of preventive treatments administered were monitored every 6 months.Results: Sixty-nine patients (M/F sex ratio 1:1; mean ± SD age at disease onset 52 ± 12 years) were included in the study. All patients had monoclonal gammopathy of immunoglobulin G type, with kappa light chains in 47 (68%). Median (interquartile range) follow-up duration was 5.1 (2.5-9.7) years. Twenty-four patients (35%) died after 3.3 (0.9-8) years. Fifty-seven (86%) patients received at least one preventive treatment, including intravenous immunoglobulins (IVIg) n = 48 (73.8%), theophylline n = 22 (33.8%), terbutaline n = 22 (33.8%), and thalidomide n = 5 (7.7%). In the 65 patients with follow-up, 5- and 10-year survival rates were 78% (n = 35) and 69% (n = 17), respectively. Multivariate analysis found preventive treatment with IVIg (hazard ratio 0.27; 95% confidence interval, 0.10-0.70; P = .007) and terbutaline (hazard ratio 0.35; 95% confidence interval, 0.13-0.96; P = .041) to be independent predictors of mortality.Conclusions: We describe the largest cohort to date of patients with well-defined monoclonal gammopathy-associated systemic capillary-leak syndrome. Preventive treatment with IVIg was the strongest factor associated with survival, suggesting the use of IVIg as the first line in prevention therapy.

Neurological complications of influenza A(H1N1) have been reported in several patients since the onset of the pandemic in 2009. However, meningococcal disease complicating influenza A(H1N1) has not been reported. Two patients were admitted to an intensive care unit (ICU) for altered mental status, fever, and rapidly spreading petechial purpura. They were diagnosed with meningococcal meningitis and/or meningococcemia and influenza A(H1N1) co-infection. Meningococcal disease presenting as meningitis and/or meningococcemia is among the potential complications of influenza A(H1N1) infection. Physicians should be aware of this co-infection, as it must be detected and treated promptly with antibiotics in addition to supportive care.

Introduction Le syndrome de fuite capillaire idiopathique (SFCI) est une maladie rare se manifestant par des episodes repetes de choc hypovolemique par fuite capillaire, en presence d’une gammapathie monoclonale. Les crises graves de SFCI sont classiquement marquees par un etat de choc hypovolemique d’intensite variable. En dehors de ce tableau typique, plusieurs cas de chocs cardiogeniques ont ete decrits au cours d’une crise grave de SCLS. L’objectif de cette etude etait de determiner la frequence, les caracteristiques et l’evolution des atteintes myocardiques au cours des crises severes de SFCI. Patients et methodes Analyse retrospective des donnees du registre international EureClark. Le diagnostic de SFCI etait retenu devant l’association d’une gammapathie monoclonale et d’au moins une crise associant ; manifestations aigues d’hypovolemie et de fuite capillaire interstitielle ; hemoconcentration et hypoprotidemie paradoxale ; exclusion des causes de syndrome de fuite capillaire secondaire. Les crises graves ayant justifie l’admission des patients en reanimation ont ete identifiees au sein du registre. Les differents services de reanimation ont ete contactes par le centre coordonnateur pour recuperer les informations concernant ces crises. Les variables continues sont exprimees en moyenne ± ecart-type ou en mediane [IQR25–75]. Resultats Entre mai 1992 et fevrier 2016, 39 patients ayant presente 64 crises graves ont ete inclus. Une atteinte myocardique etait rapportee au cours de 14 (22 %) crises chez 11 (28 %) patients. Le sex-ratio etait de 1,2 avec un âge au diagnostic de 48,2 ± 13 ans. Chez 10 (91 %) patients, une gammapathie monoclonale etait retrouvee avec une chaine legere Kappa dans 7 (70 %) cas. Huit (57 %) malades ont ete admis en reanimation pour un choc cardiogenique. Les scores IGSII et SOFA etaient respectivement de 62 [49,2–73] et 9,5 [5,7–13]. L’hemoglobine, la protidemie et la creatininemie a l’admission etaient respectivement de 19,1 [17,3–21,5] g/dL, 44 [28,7–52,5] g/L et 228 [120–294] μmol/L. Les donnees de l’echocardiographie (ETT) etaient disponibles au cours des 14 crises. Elle trouvait une hypokinesie diffuse chez 10 (71 %) patients, une hypokinesie ou une dyskinesie segmentaire chez 3 (21 %) et une hypertrophie ventriculaire sans hypokinesie chez 1 (7 %). Il existait une dysfonction ventriculaire gauche dans 13 (93 %) cas avec une fraction d’ejection du ventricule gauche a 15 [5–40] %. Un epanchement pericardique etait present dans 7 (50 %) cas. Une hypertrophie ventriculaire fugace etait rapportee chez 3 (21 %) malades. Les donnees de l’ETT se sont normalisees chez tous les survivants. La troponine etait elevee chez 12 (92,3 %, une donnee manquante) malades. Douze (85 %) patients ont necessite l’administration d’amines vasopressives, 9 (64 %) une ventilation invasive, 6 (43 %) une epuration extra-renale, 5 (36 %) une assistance circulatoire mecanique (ECMO-VA), 1 (7 %) un ballon de contre-pulsion intra-aortique et 1 (7 %) une IMPELLA © . Un syndrome des loges est survenu chez 5 (45 %) malades et 4 (36 %) sont decedes en reanimation. Nous avons ensuite compare les donnees de 39 crises de patients uniques ; 11 ayant presente une atteinte myocardique et 28 sans manifestation cardiaque. Les manifestations cliniques et biologiques etaient similaires entre les 2 groupes. Seules, les douleurs thoraciques (54 % contre 11 %, p = 0,008), la dyspnee (82 % contre 29 %, p = 0,03) et la detresse respiratoire (54 % contre 18 %, p = 0,044) etaient plus frequentes a l’admission dans le groupe atteinte cardiaque. Il n’y avait pas de difference significative en termes de traitement en reanimation, de complications et de survie, en dehors du recours a l’assistance circulatoire mecanique (36,4 % contre 0 %, p = 0,004). Conclusion La dysfonction myocardique est frequente au cours du SFCI, rapportee dans 22 % des crises. Elle est responsable d’une alteration de la fonction d’ejection ventriculaire reversible et/ou d’une hypertrophie myocardique fugace. La dysfonction myocardique peut etre severe, necessitant parfois le recours a l’assistance circulatoire mecanique. Le SFCI devrait etre ajoute a la liste des dysfonctions myocardiques severes reversibles.

Resume Le stimulus principal de la synthese et de la secretion du brain natriuretic peptide (BNP) est l’etirement des myocytes auriculaires. Le BNP est synthetise sous forme d’un precurseur inactif, le PreProBNP, qui est clive en ProBNP et en un peptide signal. Lors d’une surcharge en volume ou en pression, le ProBNP est lui-meme scinde en un peptide actif, le BNP et un peptide inactif, le NT-proBNP. Le BNP inhibe le tonus sympathique, le systeme renine-angiotensine et la synthese de nombreux vasoconstricteurs. Il est vasodilatateur, natriuretique et diuretique. Les valeurs normales de la concentration plasmatique de BNP, varient de 37 a 80 ng/l. Les concentrations du BNP et du ProBNP participent au diagnostique d’insuffisance cardiaque et sont proportionnelles au degre de gravite ; elles pourraient etre utilisees pour optimiser le traitement. Elles indiquent le risque de developper une insuffisance ventriculaire apres infarctus ou des complications apres chirurgie non cardiaque, mais augmentent de facon non discriminante apres chirurgie cardiaque. La troponine TnT est liee a la tropomyosine alors que la TnI est fixee au repos a l’actine dont elle inhibe la fixation sur la myosine. Chacune existe sous une ou des isoformes specifiques du myocarde. Les formes circulantes de troponine sont detectables dans le plasma deux a trois heures apres le debut de la necrose myocardique, le pic se situe a la 20 e heure et le taux reste eleve jusqu’au septieme jour. Toute elevation du taux est pathologique et temoigne d’une souffrance cellulaire du myocarde. Il existe une relation entre une elevation postoperatoire des troponines et le risque de complications cardiaques. La troponine peut etre elevee en cas d’embolie pulmonaire ou de choc septique en raison d’une souffrance myocardique. En cas d’insuffisance renale chronique severe, le dosage de la TnTc parait plus sensible.

Expert Rev. Ophthalmol. 3(5), 497–500 (2008) “Early diagnosis of raised intracranial pressure is critical for adequate triage and therapeutic intervention. The gold standard for intracranial pressure monitoring is the use of an invasive device, such as intraparenchymal probe or intraventricular drain” Raised intracranial pressure (ICP) is a frequent condition in neurosurgical care and is associated with poor neurological outcome. Invasive devices are the gold standard for continuous and reliable assessment of ICP. Invasive devices for monitoring ICP, however, require expertise and normal coagulation blood tests in order to be placed safely. The optic nerve is surrounded by a dura mater sheath that is distensible when cerebrospinal fluid pressure rises. Measurement of the optic nerve sheath diameter (ONSD) using ocular sonography is a simple and noninvasive tool that can be performed at the patient’s bedside. This method predicts raised ICP in various settings, including

Introduction Le syndrome de fuite capillaire idiopathique, ou syndrome de Clarkson, est une maladie rare. Le diagnostic est le plus souvent porte en reanimation lors d’une crise grave. Les caracteristiques clinicobiologiques et l’evolution des patients au cours des crises ne sont pas clairement definies. Objectif Definir la presentation clinicobiologique et l’evolution clinique au cours des crises graves de syndrome de fuite capillaire idiopathique. Analyse retrospective des donnees du registre europeen EureClark. Le diagnostic de syndrome de fuite capillaire idiopathique etait retenu devant au moins une crise associant des manifestations liees a une hypovolemie aigue (malaise, lipothymie, insuffisance renale aigue) et a une fuite capillaire simultanee (œdemes diffus, manifestations digestives, musculaires ou cardiaques) avec une hemoconcentration et une hypoalbuminemie paradoxale associee(s) a une gammapathie monoclonale. Les crises ayant justifie l’admission des patients en reanimation ont ete identifiees et les informations les concernant ont ete recuperees par le centre coordonnateur aupres des differents services de reanimation ou les malades ont ete hospitalises. Les variables continues sont exprimees en moyenne ± ecart type ou en mediane [IQR25–75]. Les variables categorielles sont exprimees en nombre et pourcentage. Resultats Vingt-cinq malades, 56 % d’hommes, presentant un total de 43 crises graves ont ete inclus dans l’etude. L’âge a l’admission etait 51±11 ans. Le delai entre le debut de la crise et l’admission en reanimation etait de 1 [0–2] jours. La duree de sejour etait de 4 [2–7] jours. Le diagnostic de syndrome de fuite capillaire idiopathique etait connu dans 49 % des cas, porte lors de 40 % des hospitalisations. Onze pour cent des crises n’ont pas abouti au diagnostic de syndrome de fuite capillaire idiopathique. Les motifs d’admission etaient : crise de syndrome de fuite capillaire idiopathique 49 %, choc hypovolemique 33 %, choc septique 9 %, choc cardiogenique 5 %, arret cardiaque 2 % et hyperviscosite 2 %. Le score Sequential Organ Failure Assessment (SOFA, de 0 a 24) a l’admission, qui permet d’evaluer la defaillance de 6 organes et l’indice de gravite simplifie II (IGS-II, allant de 0 a 163) evaluant la gravite et la probabilite de mortalite hospitaliere a partir de 15 variables etaient de 6[3–10] et 56[40–66] points. La conscience etait preservee dans 90 % des crises malgre une hypotension arterielle presente a l’admission (pression arterielle systolique : PAS 100 bpm) etait frequente, retrouvee dans 91 % des observations avec une FC de 130[110–145] bpm. Le score de Glasgow a l’admission etait de 15 [15–15] points. Les symptomes cliniques les plus frequents etaient : asthenie brutale et profonde 80 %, lipothymie 74 %, oligo-anurie 74 %, nausee et vomissement 58 %, œdemes 46 %, dyspnee 42 %, marbrures 42 %, myalgies 37 %, douleurs abdominales 35 %, sueurs profuses 30 %, diarrhee 21 %, soif 11 % et œdeme facial 5 %. La diurese a j1 etait de 300[0–650] mL et une polyurie etait presente au decours de 35 % des crises. A l’admission les parametres biologiques etaient les suivants : hemoglobine 20,6 [18,8–22,5] g/dL, hematocrite 60 [54–66] %, leucocytes 24,5 [14,2–31] G/L, plaquettes 234 [167–303] G/L, protides 50 [37–59] g/L, albumine 22 [11–30] g/L, creatinine 179 [123–251] μmol/L, lactate arteriel 5,6[4,4–8,6] mmol/L, le taux maximal de CPK etait de 1700[124–63 000] UI/L et une rhadmomyolyse (CPK > 1000UI/L) etait presente dans 57 % des cas. L’hemoglobine minimale etait de 9,8[8,2–12,2] g/dL et le delai de normalisation de l’hemoglobine etait de 1 [1–2] jours. Une saignee a ete realisee dans 7 % des cas. Un remplissage a ete conduit lors de toutes les crises avec un volume de remplissage cumule de 4,5[3,5–10,8]L. L’utilisation de noradrenaline, le recours a une technique de suppleance renale ou de ventilation invasive ont ete necessaires dans respectivement 42 %, 30 % et 30 % des cas. Un syndrome des loges est survenu lors de 25 % des crises et un traitement par immunoglobulines intraveineuses a ete conduit dans 25 % des hospitalisations pour tenter de juguler la crise. La survie a j28 des 43 crises etait de 81 %. La cause du deces etait toujours un etat de defaillance multi viscerale persistant. Conclusion Nous rapportons ici la premiere serie mondiale de crises aigues au cours du syndrome de fuite capillaire idiopathique. Ces crises conduisant les patients en reanimation sont marquees par : la preservation de la conscience des malades malgre une hypotension arterielle profonde, une hemoconcentration majeure associee a une fuite proteique paradoxale et la survenue tres frequente d’un syndrome des loges.

Stroke due to occlusion of the artery of Percheron (AOP), an uncommon anatomic variant supplying the bilateral medial thalami, may raise diagnostic challenges and cause life-threatening symptoms. Our objective here was to detail the features and outcomes in three patients who required intensive care unit (ICU) admission and to review the relevant literature.Description of three cases and literature review based on a 1973-2013 PubMed search.Three patients were admitted to our ICU with sudden-onset coma and respiratory and cardiovascular dysfunctions requiring endotracheal mechanical ventilation. Focal neurological deficits, ophthalmological signs (abnormal light reflexes and/or ocular motility and/or ptosis), and neuropsychological abnormalities were variably combined. Initial CT scan was normal. Cerebral MRI demonstrated bilateral paramedian thalamic infarction, with extension to the cerebral peduncles in two patients. Consciousness improved rapidly and time to extubation was 1-4 days. All three patients were discharged alive from the hospital and two had good 1-year functional outcomes. Similar clinical features and outcomes were recorded in the 117 patients identified in the literature, of whom ten required ICU admission.Bilateral paramedian thalamic stroke due to AOP occlusion can be life threatening. The early diagnosis relies on MRI with magnetic resonance angiography. Recovery of consciousness is usually rapid and mortality is low, warranting full-code ICU management.

We wanted to assess the diagnostic accuracy of urinary dipstick testing in excluding catheter-associated urinary tract infection (CAUTI) in intensive care unit (ICU) patients with fever or hypothermia.This was a prospective observational cohort study in a medical-surgical ICU. Patients with new-onset fever38.3 °C or hypothermia36 °C at least 48 h after urinary catheter insertion were included over a 2-year period. At each episode, a urinary dipstick test and a urine culture were performed as the criterion standard. Extensive microbiological investigations for extra-urinary infections were performed also. The performances of various urinary dipstick result combinations in ruling out CAUTI were compared based on the likelihood ratios (LR+ and LR-).Symptomatic CAUTI was diagnosed in 31 (24.4 %) of the 127 included patients (195 episodes of fever or hypothermia). LR+ was best for combined leukocyte esterase-positive and nitrite-positive dipstick results (overall population: 14.91; 95 % confidence interval [95 % CI], 5.53-40.19; patients without urinary symptoms: 15.63; 95 % CI, 5.76-42.39). LR- was best for either leukocyte esterase-positive or nitrite-positive dipstick results (overall population: 0.41; 95 % CI, 0.57-0.65; patients without urinary symptoms, 0.36; 95 % CI, 0.21-0.60).Urinary dipstick testing at the bedside does not help to rule out symptomatic CAUTI in medical or surgical ICU patients with fever or hypothermia.

Purpose We assessed the accuracy of transcranial Doppler (TCD) in helping to diagnose nonconvulsive status epilepticus (NCSE) in comatose patients admitted to the intensive care unit (ICU) for acute neurological disorders at high risk for NCSE. Methods A 2-year prospective observational study in 38 consecutive patients requiring continuous electroencephalography (EEG) monitoring and intracranial pressure monitoring with TCD. Results Of the 38 patients, 10 (26.3%) had NCSE by continuous EEG monitoring. Bilateral mean and maximal systolic and diastolic TCD velocities were significantly different between patients with and those without NCSE. Areas under the receiver-operating characteristic (ROC) curves of mean and maximal systolic velocities by TCD were 0.82 (95%CI, 0.64–1.00) and 0.79 (95%CI, 0.62–0.95) with cutoffs of 95cm/s and 105cm/s, respectively. Areas under the ROC curves of mean and maximal diastolic velocities were 0.76 (95%CI, 0.56–0.95) and 0.78 (95%CI, 0.60–0.96) with cutoffs of 31cm/s and 40cm/s, respectively. For none of the velocity parameters did the areas under the ROC curves differ significantly between the left and right sides. The best performance was obtained using mean systolic (SV) and a cutoff of 95cm/s, which yielded a positive likelihood ratio of 3.8 and a negative likelihood ratio of 0.25. Conclusion Our preliminary results showed a significant association between increased TCD velocities and NCSE in comatose patients. However, the likelihood ratios suggested a limited role for TCD in helping to diagnose seizure activity. Further studies with larger samples of NCSE patients are warranted to determine the exact contribution of TCD for NCSE detection in comatose ICU patients.

International audience; BACKGROUND: The purpose of the optic nerve sheath diameter (ONSD) research group project is to establish an individual patient-level database from high quality studies of ONSD ultrasonography for the detection of raised intracranial pressure (ICP), and to perform a systematic review and an individual patient data meta-analysis (IPDMA), which will provide a cutoff value to help physicians making decisions and encourage further research. Previous meta-analyses were able to assess the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP but failed to determine a precise cutoff value. Thus, the ONSD research group was founded to synthesize data from several recent studies on the subject and to provide evidence on the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP. METHODS: This IPDMA will be conducted in different phases. First, we will systematically search for eligible studies. To be eligible, studies must have compared ONSD ultrasonography to invasive intracranial devices, the current reference standard for diagnosing raised ICP. Subsequently, we will assess the quality of studies included based on the QUADAS-2 tool, and then collect and validate individual patient data. The objectives of the primary analyses will be to assess the diagnostic accuracy of ONSD ultrasonography and to determine a precise cutoff value for detecting raised ICP. Secondly, we will construct a logistic regression model to assess whether patient and study characteristics influence diagnostic accuracy. DISCUSSION: We believe that this IPD MA will provide the most reliable basis for the assessment of diagnostic accuracy of ONSD ultrasonography for detecting raised ICP and to provide a cutoff value. We also hope that the creation of the ONSD research group will encourage further study. TRIAL REGISTRATION: PROSPERO registration number: CRD42012003072.

Background:Posterior reversible encephalopathy syndrome (PRES) has well-established links with several drugs. Whether a link also exists with serotonin–norepinephrine reuptake inhibitor such as duloxetine is unclear.Methods:We report on a patient who developed PRES with a coma and myoclonus

Background The independent prognostic significance of postanoxic status epilepticus (PSE) has not been evaluated prospectively since the introduction of therapeutic hypothermia. We studied 1-year functional outcomes and their determinants in comatose survivors of cardiac arrest (CA), with special attention to PSE. Methods 106 comatose CA survivors admitted to the intensive care unit in 2005–2010 were included in a prospective observational study. The main outcome measure was a Cerebral Performance Category scale (CPC) of 1 or 2 (favorable outcome) 1 year after CA. Results CA occurred out-of-hospital in 89 (84%) patients and was witnessed from onset in 94 (89%). Median times were 6 min (IQR, 0–11) from CA to first-responder arrival and 23 min (14–40) from collapse to return of spontaneous circulation. PSE was diagnosed in 33 (31%) patients at a median of 39 h (4–49) after CA. PSE was refractory in 24 (22%) cases and malignant in 19 (20%). After 1 year, 31 (29.3%) patients had favorable outcomes including 2 (6.44%) with PSE. Factors independently associated with poor outcome (CPC ≥ 3) were PSE (odds ratio [OR], 14.28; 95% confidence interval [95% CI], 2.77–50.0; P = 0.001), time to restoration of spontaneous circulation (OR, 1.04/min; 95% CI, 1–1.07; P = 0.035), and LOD score on day 1 (OR, 1.28/point; 95% CI, 1.08–1.54; P = 0.003). Conclusion PSE strongly and independently predicts a poor outcome in comatose CA survivors receiving therapeutic hypothermia, but some patients with PSE survive with good functional outcomes. PSE alone is not sufficient to predict failure to awaken after CA in the era of therapeutic hypothermia.

This study was designed to optimize the latest generation venovenous (vv)-extracorporeal membrane oxygenation (ECMO)-circuit configuration and settings based on the evaluation of blood oxygenation and CO2 removal determinants in patients with severe acute respiratory distress syndrome (ARDS) on ultraprotective mechanical ventilation.Blood gases and hemodynamic parameters were evaluated after changing one of three ECMO settings, namely, circuit blood flow, FiO(2ECMO) (fraction of inspired oxygen in circuit), or sweep gas flow ventilating the membrane, while leaving the other two parameters at their maximum setting.Ten mechanically ventilated ARDS patients (mean age 44 ± 16 years; 6 males; mean hemoglobin 8.0 ± 1.8 g/dL) on ECMO for a mean of 9.0 ± 3.8 days) receiving femoro-jugular vv-ECMO were evaluated. vv-ECMO blood flow and FiO(2ECMO) determined arterial oxygenation. Decreasing the ECMO flow from its baseline maximum value (5.8 ± 0.8 L/min) to 40% less (2.4 ± 0.3 L/min) significantly decreased mean PaO2 (arterial oxygen tension; 88 ± 24 to 45 ± 9 mm Hg; p0.001) and SaO2 (oxygen saturation; 97 ± 2 to 82 ± 10%; p0.001). When the ECMO flow/cardiac output was60%, SaO2 was always90%. Alternatively, the rate of sweep gas flow through the membrane lung determined blood decarboxylation, while PaCO2 (arterial carbon dioxide tension) was unaffected when the ECMO blood flow and FiO(2ECMO) were reduced to2.5 L/min and 40%, respectively. In three additional patients evaluated before and after red blood cell transfusion, O2 delivery increased after transfusion, allowing lower ECMO flows to reach adequate SaO2.For severe ARDS patients receiving femoro-jugular vv-ECMO, blood flow was the main determinant of arterial oxygenation, while CO2 elimination depended on sweep gas flow through the oxygenator. An ECMO flow/cardiac output60% was constantly associated with adequate blood oxygenation and oxygen transport and delivery.

Introduction L’obesite, (IMC ≥ 30 kg/m 2 ), est un enjeu majeur de sante publique qui concerne 15 % des adultes en France en 2012. Si un lien est etabli entre l’IMC et la mortalite generale notamment d’origine cardiovasculaire (JAMA 1999;28:1523–9), l’effet de l’obesite sur le pronostic des patients apres un arret cardiaque (AC) recupere demeure inconnu. Notre objectif etait d’evaluer l’impact de l’IMC sur le pronostic des patients admis en reanimation apres un AC recupere. Materiel et methodes Etude retrospective bicentrique 2005–2012 de donnees pre-hospitalieres et hospitalieres collectees prospectivement de maniere standardisee (criteres d’Utstein) des patients admis pour AC recupere. Analyse statistique uni- et multivariee des facteurs associes a la mortalite hospitaliere incluant l’IMC des patients. Accord des comites d’ethique dans les 2 centres. Resultats 1449 patients ont ete admis pendant la periode d’etude, 503 exclus pour donnees manquantes (taille/poids) et 946 patients ont ete inclus dans l’etude. Les patients se repartissaient dans les classes d’IMC de la facon suivante : n = 30 (3,2 %), 18–25 n = 446 (47 %), 25–30 n = 300 (31,7 %), 30–40 n = 145 (15,3 %), > 40 n = 25 (2,6 %). La mortalite en reanimation etait significativement influencee par l’IMC et apparait sous une forme de courbe en « J » ( Figure 1 ). Les caracteristiques des patients differaient en analyse univariee sur l’âge median : 59,2 ; 62,1 ; 65,1 et egalement sur le sexe masculin : 66,6 % ; 76,7 % ; 62,4 % et la survenue d’un choc post-AC : 57,1 % ; 59,1 % ; 68,3 % pour les classes d’IMC respectivement 30. L’analyse multivariee montrait qu’un IMC > 30 etait un facteur independamment associe a la mortalite : OR 2,17 (1,31–3,6), p Discussion Notre etude suggere que l’obesite est un facteur independant de la mortalite en reanimation des patients apres AC recupere. Le recueil de la survie a un an est en cours et apportera des elements importants sur l’effet a long terme de l’obesite dans cette pathologie. Nos resultats sont en accord avec l’impact de l’IMC sur le pronostic des AC intra-hospitaliers aux USA (Circ Cardiovasc Qual Outcomes 2010;3:490–7) et sur le pronostic des AC amenes aux urgences par des paramedicaux en Autriche (Resuscitation 2011;82:869–73). Cet effet sur le pronostic pourrait etre lie a la moindre efficacite des chocs electriques et/ou a la difficulte d’abord des voies aeriennes chez les patients obeses comme en temoigne la tendance a une duree de RCP specialisee plus longue mais egalement a la difficulte de la prise en charge post-ressuscitation avec une frequence accrue d’un etat de choc post-AC. L’impact de l’IMC sur la realisation de la revascularisation coronaire et de l’hypothermie therapeutique devrait etre analyses dans de futures etudes.

BACKGROUND AND OBJECTIVE Although results of cardiac surgery are improving, octogenarians have a higher procedure-related mortality and more complications with increased length of stay in ICU. Consequently, careful evaluation of perioperative risk seems necessary. The aims of our study were to assess and compare the performances of EuroSCORE and CARE score in the prediction of perioperative mortality among octogenarians undergoing aortic valve replacement for aortic stenosis and to compare these predictive performances with those obtained in younger patients. METHODS This retrospective study included all consecutive patients undergoing cardiac surgery in our institution between November 2005 and December 2007. For each patient, risk assessment for mortality was performed using logistic EuroSCORE, additive EuroSCORE and CARE score. The main outcome measure was early postoperative mortality. Predictive performances of these scores were assessed by calibration and discrimination using goodness-of-fit test and area under the receiver operating characteristic curve, respectively. RESULTS During this 2-year period, we studied 2117 patients, among whom 134/211 octogenarians and 335/1906 nonoctogenarians underwent an aortic valve replacement for aortic stenosis. When considering patients with aortic stenosis, discrimination was poor in octogenarians and the difference from nonoctogenarians was significant for each score (0.58, 0.59 and 0.56 vs. 0.82, 0.81 and 0.77 for additive EuroSCORE, logistic EuroSCORE and CARE score in octogenarians and nonoctogenarians, respectively, P < 0.05). Moreover, in the whole cohort, logistic EuroSCORE significantly overestimated mortality among octogenarians. CONCLUSION Predictive performances of these scores are poor in octogenarians undergoing cardiac surgery, especially aortic valve replacement. Risk assessment and therapeutic decisions in octogenarians should not be made with these scoring systems alone.

Dear Editor, Status epilepticus (SE) has a long list of potential causes. In about 15% of cases, no cause is identified [1]. We report on a patient who presented with convulsive SE due to concomitant reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) in the early postpartal period. A 44-year-old nulliparous pregnant woman was admitted for labor induction at gestational week 41. Intravaginal prostaglandin gel was applied but emergency caesarean section was then performed because of recurrent fetal bradycardia. Her initial blood pressure was 110/70 mmHg. Spinal anesthesia was associated with maternal hypotension and bradycardia, which responded to ephedrine 60 mg and atropine 0.75 mg boluses followed by intravenous administration of 500 mL of crystalloids. Her blood pressure then reached up to 162/82 mmHg. She also received oxytocin 10 IU intravenously during caesarean section followed by a continuous infusion of 10 IU over the next 6 h. During the cesarean section, she experienced a thunderclap headache. Immediately after delivery, her blood pressure increased to 160/85 mmHg requiring nicardipine infusion. She experienced a first tonic–clonic seizure less than 3 h after the caesarean section, when her blood pressure was 110/60 mmHg. A second seizure occurred rapidly and stopped only after an intravenous bolus of 2 mg of midazolam and 2 g of magnesium over 30 min. A continuous 2 g/day magnesium infusion was started. A third seizure during transportation to the radiology suite required an additional intravenous bolus of 1 mg of midazolam. Figure 1a, d shows results of the first cerebral magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). She was transferred to the ICU with a diagnosis of SE related to both RCVS and PRES. On ICU admission, blurred vision was the only abnormal clinical finding. Blood pressure was 120/62 mmHg. Routine electroencephalogram was normal. On day 2, her hemodynamic status was stable, her vision was normal, and her seizures were controlled. The continuous magnesium infusion was stopped. Intravenous administration of nimodipine (2 mg/h) was started to treat

RésuméLe syndrome d’hyperviscosité plasmatique (SHV) est une urgence thérapeutique médicale dont le diagnostic est suspecté en présence de la triade associant des troubles neurologiques, sensoriels et des manifestations hémorragiques. Le diagnostic est confirmé par la mesure de la viscosité plasmatique à l’aide d’un viscosimètre. Dans un contexte évocateur, la réalisation d’un fond d’œil peut s’y substituer, les anomalies observées étant directement corrélées à l’élévation de la viscosité. Les étiologies sont dominées par la maladie de Waldenström et les autres gammapathies monoclonales. La prise en charge thérapeutique repose, outre le traitement étiologique, sur des mesures symptomatiques, visant à éviter toute aggravation de la viscosité sanguine, les techniques d’aphérèse permettant une correction rapide des manifestations cliniques.AbstractHyperviscosity syndrome is a life-threatening complication. Clinical manifestations include neurological impairment, visual disturbance and bleeding. Measurement of plasma or serum viscosity by a viscometer assesses the diagnosis. Funduscopic examination is a key exam because abnormalities are well-correlated with abnormal plasma viscosity. Etiologies are various but symptomatic hyperviscosity is more common in Waldenström's macroglobulinemia and multiple myeloma. Prompt treatment is needed: treatment of the underlying disease should be considered, but generally not sufficient. Symptomatic measures aim to not exacerbate blood viscosity while urgent plasmapheresis effectively reduces the paraprotein concentration and relieves symptoms.