Publications by authors named "Gaël Piton"

76 Publications

Impact on antimicrobial consumption of procalcitonin-guided antibiotic therapy for pneumonia/pneumonitis associated with aspiration in comatose mechanically ventilated patients: a multicenter, randomized controlled study.

Ann Intensive Care 2021 Oct 12;11(1):145. Epub 2021 Oct 12.

Medical Intensive Care Unit, University Hospital, Besançon, France.

Background: In comatose patients receiving oro-tracheal intubation for mechanical ventilation (MV), the risk of aspiration is increased. Aspiration can lead to chemical pneumonitis (inflammatory reaction to the gastric contents), or aspiration pneumonia (infection caused by inhalation of microorganisms). Distinguishing between the two types is challenging. We tested the interest of using a decisional algorithm based on procalcitonin (PCT) values to guide initiation and discontinuation of antibiotic therapies in intubated patients.

Methods: The PROPASPI (PROcalcitonin Pneumonia/pneumonitis Associated with ASPIration) trial is a multicenter, prospective, randomized, controlled, single-blind, superiority study comparing two strategies: (1) an intervention group where threshold PCT values were used to guide initiation and discontinuation of antibiotics (PCT group); and (2) a control group, where antibiotic therapy was managed at the physician's discretion. Patients aged 18 years or over, intubated for coma (Glasgow score ≤ 8), with MV initiated within 48 h after admission, were eligible. The primary endpoint was the duration of antibiotic treatment during the first 15 days after admission to the ICU.

Results: From 24/2/2015 to 28/8/2019, 1712 patients were intubated for coma in the 5 participating centers, of whom 166 were included in the study. Data from 159 were available for intention-to-treat analysis: 81 in the PCT group, and 78 in the control group. Overall, 67 patients (43%) received antibiotics in the intensive care unit (ICU); there was no significant difference between groups (37 (46%) vs 30 (40%) for PCT vs control, p = 0.432). The mean duration of antibiotic treatment during the first 15 days in the ICU was 2.7 ± 3.8 days; there was no significant difference between groups (3.0 ± 4.1 days vs 2.3 ± 3.4 days for PCT vs control, p = 0.311). The mean number of days under MV was significantly higher in the PCT group (3.7 ± 3.6 days) than in controls (2.7 ± 2.5 days, p = 0.033). The duration of ICU stay was also significantly longer in the PCT group: 6.4 ± 6.5 days vs 4.6 ± 3.5 days in the control group (p = 0.043). After adjustment for SAPS II score, the difference in length of stay and duration of mechanical ventilation between groups was no longer significant.

Conclusion: The use of PCT values to guide therapy, in comparison to the use of clinical, biological (apart from PCT) and radiological criteria, does not modify exposure to antibiotics in patients intubated for coma. Trial registration Clinicaltrials.gov Identifier NCT02862314.
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http://dx.doi.org/10.1186/s13613-021-00931-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505789PMC
October 2021

Reply to "Atherosclerosis is a risk factor of mortality in patients with non-occlusive mesenteric ischemia".

Eur J Radiol 2021 09 29;142:109836. Epub 2021 Jun 29.

Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030 Besançon, France; EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, Besançon, France.

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http://dx.doi.org/10.1016/j.ejrad.2021.109836DOI Listing
September 2021

Timing and causes of death in severe COVID-19 patients.

Crit Care 2021 06 30;25(1):224. Epub 2021 Jun 30.

Intensive Care Unit, Gustave Roussy, Université Paris-Saclay, Villejuif, France.

Background: Previous studies reporting the causes of death in patients with severe COVID-19 have provided conflicting results. The objective of this study was to describe the causes and timing of death in patients with severe COVID-19 admitted to the intensive care unit (ICU).

Methods: We performed a retrospective study in eight ICUs across seven French hospitals. All consecutive adult patients (aged ≥ 18 years) admitted to the ICU with PCR-confirmed SARS-CoV-2 infection and acute respiratory failure were included in the analysis. The causes and timing of ICU deaths were reported based on medical records.

Results: From March 1, 2020, to April 28, 287 patients were admitted to the ICU for SARS-CoV-2 related acute respiratory failure. Among them, 93 patients died in the ICU (32%). COVID-19-related multiple organ dysfunction syndrome (MODS) was the leading cause of death (37%). Secondary infection-related MODS accounted for 26% of ICU deaths, with a majority of ventilator-associated pneumonia. Refractory hypoxemia/pulmonary fibrosis was responsible for death in 19% of the cases. Fatal ischemic events (venous or arterial) occurred in 13% of the cases. The median time from ICU admission to death was 15 days (25th-75th IQR, 7-27 days). COVID-19-related MODS had a median time from ICU admission to death of 14 days (25th-75th IQR: 7-19 days), while only one death had occurred during the first 3 days since ICU admission.

Conclusions: In our multicenter observational study, COVID-19-related MODS and secondary infections were the two leading causes of death, among severe COVID-19 patients admitted to the ICU.
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http://dx.doi.org/10.1186/s13054-021-03639-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243043PMC
June 2021

Evaluating the Risk of Irreversible Intestinal Necrosis Among Critically Ill Patients With Nonocclusive Mesenteric Ischemia.

Am J Gastroenterol 2021 07;116(7):1506-1513

Medical Intensive Care Unit, University of Bourgogne Franche-Comté, CHRU Besançon, Besançon, France.

Introduction: To identify factors associated with irreversible transmural necrosis (ITN) among critically ill patients experiencing nonocclusive mesenteric ischemia (NOMI) and to compare the predictive value regarding ITN risk stratification with that of the previously described Clichy score.

Methods: All consecutive patients admitted to the intensive care unit between 2009 and 2019 who underwent exploratory laparotomy for NOMI and who had an available contrast-enhanced computed tomography with at least 1 portal venous phase were evaluated for inclusion. Clinical, laboratory, and radiological variables were collected. ITN was assessed on pathological reports of surgical specimens and/or on laparotomy findings in cases of open-close surgery. Factors associated with ITN were identified by univariate and multivariate analysis to derive a NOMI-ITN score. This score was further compared with the Clichy score.

Results: We identified 4 factors associated with ITN in the context of NOMI: absence of bowel enhancement, bowel thinning, plasma bicarbonate concentration ≤15 mmol/L, and prothrombin rate <40%. These factors were included in a new NOMI-ITN score, with 1 point attributed for each variable. ITN was observed in 6%, 38%, 65%, 88%, and 100% of patients with NOMI-ITN score ranging from 0 to 4, respectively. The NOMI-ITN score outperformed the Clichy score for the prediction of ITN (area under the receiver operating characteristics curve 0.882 [95% confidence interval 0.826-0.938] vs 0.674 [95% confidence interval 0.582-0.766], respectively, P < 0.001).

Discussion: We propose a new 4-point score aimed at stratifying risk of ITN in patients with NOMI. The Clichy score should be applied to patients with occlusive acute mesenteric ischemia only.
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http://dx.doi.org/10.14309/ajg.0000000000001274DOI Listing
July 2021

Extracorporeal Membrane Oxygenation Cannula-Related Infections: Epidemiology and Risk Factors.

ASAIO J 2021 Jun 1. Epub 2021 Jun 1.

From the Medical Intensive Care Unit, University Hospital, Besancon, France Research Unit EA 3920, University of Franche Comte, Besancon, France Anaesthesia and Surgical Intensive Care Unit, University Hospital, Besancon, France Bacteriology Department, University Hospital, Besancon, France Cardiac Surgery Unit, University Hospital, Besancon, France Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia.

Although being a potential major source of infection in extracorporeal membrane oxygenation (ECMO) patients, data regarding cannula-related infections (CRI) remain scarce. We therefore aimed at describing the epidemiology of CRI among critically ill patients supported by ECMO. Between October 2017 and November 2019, adult patients supported by either venoarterial (VA), venopulmonary arterial, or venovenous (VV) ECMO for more than 24 hours were prospectively enrolled. When CRI was suspected, cannula swab and subcutaneous needle aspirate samples were obtained for microbiological culture. Cannula tips were systematically sent for culture at the time of ECMO removal. Primary end-point was CRI, which was defined by sepsis or local sign of cannula infection and at least one positive culture among swab, subcutaneous needle aspirate or tip. Multivariate analysis was performed to identify risk factors of CRI. Hundred patients were included, including 77 VA, 12 venopulmonary arterial, and 11 VV ECMO. Cannula-related infections were diagnosed after a median duration of ECMO of 10 [7-13] days. Rate of CRI was 24%, including 10% with bacteremia. Most frequent involved pathogens were Enterobacteriaceae (n = 14), Enterococci (n = 8), and coagulase-negative Staphylococci (n = 7). By multivariate analysis, diabetes and ECMO duration were independently associated with CRI.
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http://dx.doi.org/10.1097/MAT.0000000000001505DOI Listing
June 2021

Impact of early low-calorie low-protein versus standard-calorie standard-protein feeding on outcomes of ventilated adults with shock: design and conduct of a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3).

BMJ Open 2021 05 11;11(5):e045041. Epub 2021 May 11.

Service de Médecine Intensive Réanimation, Centre Hospitalier de Valenciennes, Valenciennes, France.

Introduction: International guidelines include early nutritional support (≤48 hour after admission), 20-25 kcal/kg/day, and 1.2-2 g/kg/day protein at the acute phase of critical illness. Recent data challenge the appropriateness of providing standard amounts of calories and protein during acute critical illness. Restricting calorie and protein intakes seemed beneficial, suggesting a role for metabolic pathways such as autophagy, a potential key mechanism in safeguarding cellular integrity, notably in the muscle, during critical illness. However, the optimal calorie and protein supply at the acute phase of severe critical illness remains unknown. NUTRIREA-3 will be the first trial to compare standard calorie and protein feeding complying with guidelines to low-calorie low-protein feeding. We hypothesised that nutritional support with calorie and protein restriction during acute critical illness decreased day 90 mortality and/or dependency on intensive care unit (ICU) management in mechanically ventilated patients receiving vasoactive amine therapy for shock, compared with standard calorie and protein targets.

Methods And Analysis: NUTRIREA-3 is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients receiving invasive mechanical ventilation and vasoactive amine therapy for shock and given early nutritional support according to one of two strategies: early calorie-protein restriction (6 kcal/kg/day-0.2-0.4 g/kg/day) or standard calorie-protein targets (25 kcal/kg/day, 1.0-1.3 g/kg/day) at the acute phase defined as the first 7 days in the ICU. We will include 3044 patients in 61 French ICUs. Two primary end-points will be evaluated: day 90 mortality and time to ICU discharge readiness. The trial will be considered positive if significant between-group differences are found for one or both alternative primary endpoints. Secondary outcomes include hospital-acquired infections and nutritional, clinical and functional outcomes.

Ethics And Dissemination: The NUTRIREA-3 study has been approved by the appropriate ethics committee. Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals.

Trial Registration Number: NCT03573739.
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http://dx.doi.org/10.1136/bmjopen-2020-045041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117996PMC
May 2021

Serum phosphate is associated with mortality among patients admitted to ICU for acute pancreatitis.

United European Gastroenterol J 2021 Jun 5;9(5):534-542. Epub 2021 May 5.

Service de Réanimation Médicale, CHRU Jean Minjoz, Besançon, France.

Background And Aims: Routine laboratory tests can be useful predictors in the early assessment of the severity and mortality of acute pancreatitis (AP). The aim of this study was to evaluate the accuracy of clinical and laboratory parameters for the prediction of mortality among patients admitted to the intensive care unit (ICU) for AP.

Methods: We conducted a retrospective analysis of prospectively collected data from Beth Israel Deaconess Hospital made publicly available to examine the relationship between routine clinical and laboratory parameters with respect to mortality for AP. Cox proportional hazard ratio was used to evaluate the impact of several routine laboratory markers on mortality. Receiver operation characteristic (ROC) curve was performed to determine the accuracy of diagnosis of laboratory tests by using area under curve (AUC) for the respective analysis.

Results: In total, 499 patients were admitted to the ICU for AP. Several factors for predicting mortality in AP at admission were identified in the multivariate analysis: alkaline phosphatase hazard ratio (HR) = 1.00 (1.00-1.00, p = 0.024), anion gap HR = 1.09 (1.00-1.20, p = 0.047), bilirubin total HR = 1.11 (1.06-1.17, p < 0.001), calcium total HR = 0.59 (0.42-0.84, p = 0.004), phosphate HR = 1.51 (1.18-1.94, p = 0.001), potassium HR = 1.91 (1.03-3.55, p = 0.041), white blood cells HR = 1.04 (1.00-1.07, p = 0.028). The AUC of serum phosphate level for mortality was 0.7 in the ROC analysis. The optimal cut-off value of serum phosphate level for prediction of mortality was 3.78 mg/dl (sensitivity, 0.58; specificity, 0.78).

Conclusion: In this large cohort, we identified baseline serum phosphate as the most valuable single routine laboratory test for predicting mortality in AP. Future prospective studies are required to confirm these results.
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http://dx.doi.org/10.1002/ueg2.12059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259433PMC
June 2021

New clinical algorithm including fungal biomarkers to better diagnose probable invasive pulmonary aspergillosis in ICU.

Ann Intensive Care 2021 Mar 8;11(1):41. Epub 2021 Mar 8.

Parasitology-Mycology Department, University Hospital of Besançon, 25000, Besançon, France.

Background: The classification of invasive pulmonary aspergillosis (IPA) issued by the European Organization for the Research and Treatment of Cancer/Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) is used for immunocompromised patients. An alternative algorithm adapted to the intensive care unit (ICU) population has been proposed (AspICU), but this algorithm did not include microbial biomarkers such as the galactomannan antigen and the Aspergillus quantitative PCR. The objective of the present pilot study was to evaluate a new algorithm that includes fungal biomarkers (BM-AspICU) for the diagnosis of probable IPA in an ICU population.

Patients And Methods: Data from 35 patients with pathology-proven IPA according to European Organization for the Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSGERC)-2008 criteria were extracted from the French multicenter database of the Invasive Fungal Infections Surveillance Network (RESSIF). The patients were investigated according to the AspICU algorithm, and the BM-AspICU algorithm in analyzing the clinical, imaging, and biomarker data available in the records, without taking into account the pathology findings.

Results: Eight patients had to be excluded because no imaging data were recorded in the database. Among the 27 proven IPAs with complete data, 16 would have been considered as putative IPA with the AspICU algorithm and 24 would have been considered as probable IPA using the new algorithm BM-AspICU. Seven out of the 8 patients with probable BM-AspICU IPA (and not classified with the AspICU algorithm) had no host factors and no Aspergillus-positive broncho-alveolar lavage fluid (BALF) culture. Three patients were non-classifiable with any of the two algorithms, because they did not have any microbial criteria during the course of the infection, and diagnosis of proven aspergillosis was done using autopsy samples.

Conclusion: Inclusion of biomarkers could be effective to identify probable IPA in the ICU population. A prospective study is needed to validate the routine application of the BM-AspICU algorithm in the ICU population.
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http://dx.doi.org/10.1186/s13613-021-00827-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938267PMC
March 2021

Diagnostic performance of CT for the detection of transmural bowel necrosis in non-occlusive mesenteric ischemia.

Eur Radiol 2021 Sep 14;31(9):6835-6845. Epub 2021 Feb 14.

Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France.

Objectives: To evaluate the diagnostic performance of CT for transmural necrosis (TN) in non-occlusive mesenteric ischemia (NOMI) according to the bowel segment involved.

Methods: From January 2009 to December 2019, all patients admitted to the intensive care unit (ICU) and requiring laparotomy for NOMI were retrospectively studied. CT had to have been performed within 24 h prior to laparotomy and were reviewed by two abdominal radiologists, with a consensus reading in case of disagreement. A set of CT features of mesenteric ischemia were assessed, separating the stomach, jejunum, ileum, and right (RC) and left colon (LC). Univariate and multivariate analyses were performed to identify features associated with TN. Its influence on overall survival (OS) was assessed.

Results: Among 145 patients, 95 (66%) had ≥ 1 bowel segment with TN, including 7 (5%), 31 (21%), 43 (29%), 45 (31%), and 52 (35%) in the stomach, jejunum, ileum, RC, and LC, respectively. Overall inter-reader agreement of CT features was significantly lower in the colon than in the small bowel (0.59 [0.52-0.65] vs 0.74 [0.70-0.77] respectively). The absence of bowel wall enhancement was the only CT feature associated with TN by multivariate analysis, whatever the bowel segment involved. Proximal TN was associated with poorer OS (p < 0.001).

Conclusions: The absence of bowel wall enhancement remains the most consistent CT feature of transmural necrosis, whatever the bowel segment involved in NOMI. Inter-reader agreement of CT features is lower in the colon than in the small bowel. Proximal TN seems to be associated with poorer OS.

Key Points: • The absence of bowel wall enhancement is the most consistent CT feature associated with transmural necrosis in NOMI, whatever is the bowel segment involved. • Inter-reader agreement is lower in the colon than in the small bowel in NOMI. • In NOMI, the more proximal the bowel necrosis, the worse the prognosis.
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http://dx.doi.org/10.1007/s00330-021-07728-wDOI Listing
September 2021

Relationship Between Obesity and Ventilator-Associated Pneumonia: A Post Hoc Analysis of the NUTRIREA2 Trial.

Chest 2021 06 6;159(6):2309-2317. Epub 2021 Feb 6.

Medecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France.

Background: Patients with obesity are at higher risk for community-acquired and nosocomial infections. However, no study has specifically evaluated the relationship between obesity and ventilator-associated pneumonia (VAP).

Research Question: Is obesity associated with an increased incidence of VAP?

Study Design And Methods: This study was a post hoc analysis of the Impact of Early Enteral vs Parenteral Nutrition on Mortality in Patients Requiring Mechanical Ventilation and Catecholamines (NUTRIREA2) open-label, randomized controlled trial performed in 44 French ICUs. Adults receiving invasive mechanical ventilation and vasopressor support for shock and parenteral nutrition or enteral nutrition were included. Obesity was defined as BMI ≥ 30 kg/m at ICU admission. VAP diagnosis was adjudicated by an independent blinded committee, based on all available clinical, radiologic, and microbiologic data. Only first VAP episodes were taken into account. Incidence of VAP was analyzed by using the Fine and Gray model, with extubation and death as competing risks.

Results: A total of 699 (30%) of the 2,325 included patients had obesity; 224 first VAP episodes were diagnosed (60 and 164 in obese and nonobese groups, respectively). The incidence of VAP at day 28 was 8.6% vs 10.1% in the two groups (hazard ratio, 0.85; 95% CI 0.63-1.14; P = .26). After adjustment on sex, McCabe score, age, antiulcer treatment, and Sequential Organ Failure Assessment at randomization, the incidence of VAP remained nonsignificant between obese and nonobese patients (hazard ratio, 0.893; 95% CI, 0.66-1.2; P = .46). Although no significant difference was found in duration of mechanical ventilation and ICU length of stay, 90-day mortality was significantly lower in obese than in nonobese patients (272 of 692 [39.3%] patients vs 718 of 1,605 [44.7%]; P = .02). In a subgroup of patients (n = 123) with available pepsin and alpha-amylase measurements, no significant difference was found in rate of abundant microaspiration of gastric contents, or oropharyngeal secretions between obese and nonobese patients.

Interpretation: Our results suggest that obesity has no significant impact on the incidence of VAP.
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http://dx.doi.org/10.1016/j.chest.2021.01.081DOI Listing
June 2021

Acute cholangitis in intensive care units: clinical, biological, microbiological spectrum and risk factors for mortality: a multicenter study.

Crit Care 2021 02 6;25(1):49. Epub 2021 Feb 6.

Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.

Background: Little is known on the outcome and risk factors for mortality of patients admitted in Intensive Care units (ICUs) for Acute cholangitis (AC).

Methods: Retrospective multicenter study included adults admitted in eleven intensive care units for a proven AC from 2005 to 2018. Risk factors for in-hospital mortality were identified using multivariate analysis.

Results: Overall, 382 patients were included, in-hospital mortality was 29%. SOFA score at admission was 8 [5-11]. Biliary obstruction was mainly related to gallstone (53%) and cancer (22%). Median total bilirubin and PCT were respectively 83 µmol/L [50-147] and 19.1 µg/L [5.3-54.8]. Sixty-three percent of patients (n  = 252) had positive blood culture, mainly Gram-negative bacilli (86%) and 14% produced extended spectrum beta lactamase bacteria. At ICU admission, persisting obstruction was frequent (79%) and biliary decompression was performed using therapeutic endoscopic retrograde cholangiopancreatography (76%) and percutaneous transhepatic biliary drainage (21%). Adjusted mortality significantly decreased overtime, adjusted OR for mortality per year was 0.72 [0.54-0.96] (p = 0.02). In a multivariate analysis, factors at admission associated with in-hospital mortality were: SOFA score (OR 1.14 [95% CI 1.05-1.24] by point, p = 0.001), lactate (OR 1.21 [95% CI 1.08-1.36], by 1 mmol/L, p < 0.001), total serum bilirubin (OR 1.26 [95% CI 1.12-1.41], by 50 μmol/L, p < 0.001), obstruction non-related to gallstones (p < 0.05) and AC complications (OR 2.74 [95% CI 1.45-5.17], p = 0.002). Time between ICU admission and biliary decompression > 48 h was associated with in-hospital mortality (adjusted OR 2.73 [95% CI 1.30-6.22], p = 0.02).

Conclusions: In this large retrospective multicenter study, we found that AC-associated mortality significantly decreased overtime. Severity of organ failure, cause of obstruction and local complications of AC are risk factors for mortality, as well as delayed biliary drainage > 48 h.
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http://dx.doi.org/10.1186/s13054-021-03480-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866656PMC
February 2021

Increased susceptibility to intensive care unit-acquired pneumonia in severe COVID-19 patients: a multicentre retrospective cohort study.

Ann Intensive Care 2021 Jan 29;11(1):20. Epub 2021 Jan 29.

3i Department, Team Pulmonary and Systemic Immune Responses During Acute and Chronic Bacterial Infections, Institut Cochin, INSERM U1016, CNRS UMR8104, Université de Paris, Paris, France.

Background: The aim of this study is to determine whether severe COVID-19 patients harbour a higher risk of ICU-acquired pneumonia.

Methods: This retrospective multicentre cohort study comprised all consecutive patients admitted to seven ICUs for severe COVID-19 pneumonia during the first COVID-19 surge in France. Inclusion criteria were laboratory-confirmed SARS-CoV-2 infection and requirement for invasive mechanical ventilation for 48 h or more. Control groups were two historical cohorts of mechanically ventilated patients admitted to the ICU for bacterial or non-SARS-CoV-2 viral pneumonia. The outcome of interest was the development of ICU-acquired pneumonia. The determinants of ICU-acquired pneumonia were investigated in a multivariate competing risk analysis.

Result: One hundred and seventy-six patients with severe SARS-CoV-2 pneumonia admitted to the ICU between March 1st and 30th June of 2020 were included into the study. Historical control groups comprised 435 patients with bacterial pneumonia and 48 ones with viral pneumonia. ICU-acquired pneumonia occurred in 52% of COVID-19 patients, whereas in 26% and 23% of patients with bacterial or viral pneumonia, respectively (p < 0.001). Times from initiation of mechanical ventilation to ICU-acquired pneumonia were similar across the three groups. In multivariate analysis, the risk of ICU-acquired pneumonia remained independently associated with underlying COVID-19 (SHR = 2.18; 95 CI 1.2-3.98, p = 0.011).

Conclusion: COVID-19 appears an independent risk factor of ICU-acquired pneumonia in mechanically ventilated patients with pneumonia. Whether this is driven by immunomodulatory properties by the SARS-CoV-2 or this is related to particular processes of care remains to be investigated.
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http://dx.doi.org/10.1186/s13613-021-00812-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844782PMC
January 2021

Prevalence of pressure injuries among critically ill patients and factors associated with their occurrence in the intensive care unit: The PRESSURE study.

Aust Crit Care 2021 09 20;34(5):411-418. Epub 2021 Jan 20.

CERC, SRLF, France. Electronic address:

Background: The prevalence of pressure injuries (PIs) in critically ill patients has been extensively studied, but there is uncertainty regarding the risk factors. The main objective of this study was to describe the prevalence of PIs in critically ill patients. Secondary objectives were to describe PI, use of preventive measures for PI, and factors associated with occurrence of PI in the intensive care unit (ICU).

Material And Methods: This was a 1-day point-prevalence study performed on a weekday in June 2017 in ICUs in France. On the same day, we noted the presence or absence of PI in all hospitalised patients of the participating ICUs, data on the ICUs, and the characteristics of patients and of PI.

Results: Eighty-six participating ICUs allowed the inclusion of 1228 patients. The prevalence of PI on the study day was 18.7% (95% confidence interval: 16.6-21.0). PIs acquired in the ICU were observed in 12.5% (95% confidence interval: 10.6-14.3) of critically ill patients on the study day. The most frequent locations of PI were the sacrum (57.4%), heel (35.2%), and face (8.7%). Severe forms of PI accounted for 40.8% of all PIs. Antiulcer mattresses were used in 91.5% of the patients, and active and/or passive mobilisation was performed for all the patients. Multiple logistic regression analysis identified longer length of stay in the ICU, a higher Simplified Acute Physiology Score, higher body weight, motor neurological disorder, high-dose steroids, and absence of oral nutrition on the study day as factors independently associated with occurrence of PI in the ICU.

Conclusion: This large point-prevalence study shows that PIs are found in about one of five critically ill patients despite extensive use of devices for preventing PI. Acquisition of PI in the ICU is strongly related to the patient's severity of illness on admission to the ICU and length of stay in the ICU.
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http://dx.doi.org/10.1016/j.aucc.2020.12.001DOI Listing
September 2021

Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients: a randomized trial.

Crit Care 2021 01 20;25(1):31. Epub 2021 Jan 20.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France.

Background: The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients.

Methods: Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h.

Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea.

Results: Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44-65] versus 55[40-65] years) and GCS (6[3-7] versus 5[3-7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78-1.42); p = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day (p = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day (p < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis (p = 0.21), and 16% versus 8% patients suffered from diarrhea (p = 0.11). No patient presented vomiting in either group.

Conclusion: Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition.

Trial Registration: EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).
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http://dx.doi.org/10.1186/s13054-020-03456-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818740PMC
January 2021

The prognostic value of the neutrophil-to-lymphocyte ratio in critically ill cirrhotic patients.

Eur J Gastroenterol Hepatol 2021 Jan 18. Epub 2021 Jan 18.

Department of Anesthesiology and Critical Care, APHP, Beaujon Hospital, Clichy Medical Intensive Care Unit, Rouen University Hospital, Rouen UMR_S 1149 Centre for research on Inflammation - Inserm/Université de Paris, Paris Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS, UMR 9214, Montpellier Département Hospitalo-Universitaire UNITY, Service d'Hépatologie, APHP, Hôpital Beaujon, Clichy Medical Intensive Care Unit, University Hospital of Besancon, Besançon Normandie University, UNIROUEN, INSERM U1096 EnVI, Rouen, France.

Background: Hospital death rates following ICU admission of cirrhotic patients remain high. Identifying patients at high risk of mortality after few days of aggressive management is imperative for providing adequate interventions. Herein, we aimed to evaluate the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) combined with usual organ failure scores in the outcome prediction of cirrhotic patients hospitalized more than 3 days in ICU.

Methods: We conducted a retrospective bicentric study in two cohorts of cirrhotic patients hospitalized more than 3 days in French university hospital ICUs. At admission and day 3, we calculated several clinico-biological scores grading liver disease and organ failure severity and calculated the NLR. The primary outcome was 28-day mortality.

Results: The test cohort included 116 patients. At day 28, 43 (37.1%) patients had died. Variations of MELD score (ΔMELD), SOFA score (ΔSOFA), CLIF-SOFA score (ΔCLIF-SOFA) and NLR (ΔNRL) between admission and day 3 were significantly associated with 28-day mortality in univariate analysis. When included in bivariate analysis ΔNLR remained a significant predictor of 28-day mortality independently of these severity scores. Kaplan-Meier curves and statistics using reclassification methods showed a better 28-day mortality risk prediction using ΔNRL in association with ΔSOFA in comparison to ΔSOFA alone. These results were confirmed in an external validation cohort, including 101 critically ill cirrhotic patients.

Conclusions: ΔNLR is an independent predictor of mortality in the critically ill cirrhotic patients' population who requires intensive care supportive treatment and should be used in association with ΔSOFA as a prognostic biomarker.
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http://dx.doi.org/10.1097/MEG.0000000000002063DOI Listing
January 2021

Atherosclerosis is associated with poorer outcome in non-occlusive mesenteric ischemia.

Eur J Radiol 2021 Jan 30;134:109453. Epub 2020 Nov 30.

Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France.

Purpose: To evaluate whether abdominal atherosclerosis was associated with poorer outcome in a single-centre cohort of patients suffering from nonocclusive mesenteric ischemia (NOMI).

Methods: From January 2009 to December 2019, 121 consecutive patients from the critical care unit who underwent laparotomy for suspected NOMI and with available unenhanced and contrast-enhanced CT were included. Clinical and biological data at the time of the CT scan were retrospectively extracted from medical charts and reviewed by a single radiologist. Unenhanced CT acquisitions were used to calculate calcium scores of the abdominal aorta, celiac trunk, superior mesenteric artery (SMA) and common iliac arteries according to the Agatston method. Univariate and multivariate analysis were performed.

Results: Among the 121 patients with NOMI and calcium score calculation, only 4 patients had no aortic calcifications (3 %) and 32 had no superior mesenteric artery calcification (26 %). 35 patients (29 %) died within 24 h after the abdominal CT scan. Univariate analysis showed that a total abdominal calcium score greater than 15 000 (last quartile) was significantly associated with death within 24 h (14 (40 %) vs 17 (20 %) patients, p = 0.035). By multivariate analysis, a total abdominal calcium score greater than 15 000 was an independent risk factor for death (HR = 1.94, 95 %CI [1.02-3.73], p = 0.044). Regarding separate calcium scores, only a SMA calcium score greater than 50 was a risk factor for death (HR 2.46, 95 %CI [1.14-3.93], p = 0.019).

Conclusion: Our results show that abdominal atherosclerosis, especially in the SMA, is associated with poorer outcome in NOMI.
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http://dx.doi.org/10.1016/j.ejrad.2020.109453DOI Listing
January 2021

Adverse Events in Intensive Care and Continuing Care Units During Bed-Bath Procedures: The Prospective Observational NURSIng during critical carE (NURSIE) Study.

Crit Care Med 2021 01;49(1):e20-e30

Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire, Chemin des Bourrely, Marseille, France.

Objectives: Standard nursing interventions, especially bed-baths, in ICUs can lead to complications or adverse events defined as a physiologic change that can be life-threatening or that prolongs hospitalization. However, the frequency and type of these adverse events are rarely reported in the literature. The primary objective of our study was to describe the proportion of patients experiencing at least one serious adverse event during bed-bath. The secondary objectives were to determine the incidence of each type of serious adverse event and identify risk factors for these serious adverse events.

Design: Prospective multicenter observational study.

Setting: Twenty-four ICUs in France, Belgium, and Luxembourg.

Patients: The patients included in this study had been admitted to an ICU for less than 72 hours and required at least one of the following treatments: invasive ventilation, vasopressors, noninvasive ventilation, high-flow oxygen therapy. Serious adverse events were defined as cardiac arrest, accidental extubation, desaturation and/or mucus plugging/inhalation, hypotension and/or arrhythmia and/or agitation requiring therapeutic intervention, acute pain, accidental disconnection or dysfunction of equipment, and patient fall requiring additional assistance.

Interventions: None.

Measurements And Main Results: The study included 253 patients from May 1, 2018, to July 31, 2018 in 24 ICUs, representing 1,529 nursing procedures. The mean Simplified Acute Physiology Score II was 54 ± 19. Nursing care was administered by an average of 2 ± 1 caregivers and lasted between 11 and 20 minutes. Of the 253 patients included, 142 (56%) experienced at least one serious adverse event. Of the 1,529 nursing procedures, 295 (19%) were complicated by at least one serious adverse event. In multivariate analysis, the factors associated with serious adverse event were as follows: presence of a specific protocol (p = 0.011); tracheostomy (p = 0.032); administration of opioids (p = 0.007); presence of a physician (p = 0.0004); duration of nursing care between 6 and 10 minutes (p = 0.003), duration of nursing care between 11 and 20 minutes (p = 0.005), duration of nursing care greater than 40 minutes (p = 0.04) with a reference duration of nursing care between 20 and 40 minutes.

Conclusions: Serious adverse events were observed in one-half of patients and concerned one-fifth of nurses, confirming the need for caution. Further studies are needed to test systematic serious adverse event prevention strategies.
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http://dx.doi.org/10.1097/CCM.0000000000004745DOI Listing
January 2021

Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Possible Late Indication for Coronavirus Disease 2019?

Crit Care Explor 2020 Oct 6;2(10):e0240. Epub 2020 Oct 6.

Service de Réanimation médicale, Centre Hospitalier Universitaire Besançon, Besançon, France.

Background: There is now substantial evidence to support venovenous extracorporeal membrane oxygenation efficacy and safety for patients with severe acute respiratory distress syndrome. However, recent guidelines recommend against the initiation of extracorporeal membrane oxygenation in patients with mechanical ventilation for coronavirus disease 2019 severe acute respiratory distress syndrome for greater than 7-10 days.

Case Summary: We report the case of a patient with coronavirus disease 2019 severe acute respiratory distress syndrome with successful late venovenous extracorporeal membrane oxygenation initiation after 20 days of mechanical ventilation. Respiratory compliance, arterial blood gases, and radiological lesions improved progressively under venovenous extracorporeal membrane oxygenation and ultraprotective ventilation. The patient was discharged from ICU.

Conclusions: As coronavirus disease 2019 is a new and incompletely understood entity, we believe that late extracorporeal membrane oxygenation may be considered in selected patients as a bridge to recovery. Further prospective studies are, however, needed.
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http://dx.doi.org/10.1097/CCE.0000000000000240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540917PMC
October 2020

Factors Associated With Pulmonary Embolism Among Coronavirus Disease 2019 Acute Respiratory Distress Syndrome: A Multicenter Study Among 375 Patients.

Crit Care Explor 2020 Jul 25;2(7):e0166. Epub 2020 Jun 25.

Service de Réanimation Médicale, CHU Besançon, Besançon, France.

Risk factors associated with pulmonary embolism in coronavirus disease 2019 acute respiratory distress syndrome patients deserve to be better known. We therefore performed a post hoc analysis from the COronaVirus-Associated DIsease Study (COVADIS) project, a multicenter observational study gathering 21 ICUs from France ( = 12) and Belgium ( = 9). Three-hundred seventy-five consecutive patients with moderate-to-severe acute respiratory distress syndrome and positive coronavirus disease 2019 were included in the study. At day 28, 15% were diagnosed with pulmonary embolism. Known risk factors for pulmonary embolism including cancer, obesity, diabetes, hypertension, and coronary artery disease were not associated with pulmonary embolism. In the multivariate analysis, younger age (< 65 yr) (odds ratio, 2.14; 1.17-4.03), time between onset of symptoms and antiviral administration greater than or equal to 7 days (odds ratio, 2.39; 1.27-4.73), and use of neuromuscular blockers greater than or equal to 7 days (odds ratio, 1.89; 1.05-3.43) were independently associated with pulmonary embolism. These new findings reinforce the need for prospective studies that will determine the predictors of pulmonary embolism among patients with severe coronavirus disease 2019.
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http://dx.doi.org/10.1097/CCE.0000000000000166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7339309PMC
July 2020

Metaphor use in the ICU: rigor with words!

Intensive Care Med 2020 11 18;46(11):2126-2127. Epub 2020 Jun 18.

Intensive Care Unit, Besançon University Hospital, Besançon, France.

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http://dx.doi.org/10.1007/s00134-020-06156-6DOI Listing
November 2020

Refractory ARDS with diffuse centrilobular nodules: did the patient smoke a tree?

Postgrad Med J 2021 Feb 28;97(1144):127. Epub 2020 May 28.

Medical Intensive Care Unit, University Hospital of Besançon, Besançon, France.

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http://dx.doi.org/10.1136/postgradmedj-2020-138010DOI Listing
February 2021

Initial pH and shockable rhythm are associated with favorable neurological outcome in cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation.

J Thorac Dis 2020 Mar;12(3):849-857

Medical Intensive Care Unit, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia.

Background: There is uncertainty about best selection criteria for extracorporeal cardiopulmonary resuscitation (eCPR) in the setting of refractory cardiac arrest. We aimed to identify factors associated with a favorable neurological outcome, and to build a score calculable at the time of ECMO insertion predicting the prognosis.

Methods: Retrospective analysis of all patients who underwent eCPR between 2010 and 2017 in a single university hospital. Primary end point was survival with favorable neurological outcome at intensive care unit (ICU) discharge defined as a Cerebral Performance Category of 1 or 2.

Results: Overall low-flow time of the 113 included patients was 84 [55-122] minutes. Eighteen patients (16%) survived with a favorable neurological outcome. By multivariate logistic regression analysis, initial shockable rhythm, and arterial blood pH at the time of eCPR implantation ≥7.0, were independent predictors of survival with favorable neurological outcome. All of the patients presenting with both non-shockable rhythm and pH <7.0 at the time of eCPR implantation died in the ICU.

Conclusions: At the time of eCPR start, only initial shockable rhythm and arterial pH ≥7.0 predicted neurological outcome. A selection of the patients who might benefit from eCPR, based upon initial rhythm and arterial pH rather than on low flow time, should be further evaluated.
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http://dx.doi.org/10.21037/jtd.2019.12.127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139075PMC
March 2020

Sarcopenia and visceral obesity assessed by computed tomography are associated with adverse outcomes in patients with Crohn's disease.

Clin Nutr 2020 10 11;39(10):3024-3030. Epub 2020 Jan 11.

Department of Gastroenterology and Nutrition, University Hospital of Besançon, University Bourgogne Franche-Comté, 25030 Besançon, France. Electronic address:

Background: Altered body composition may impact on the clinical course of Crohn's disease (CD) but is not detected by the simple body mass index (BMI) assessment.

Aim: To assess the prevalence of sarcopenia and visceral obesity by a single computed tomography (CT) slice, and its association with adverse events in an adult hospitalized CD cohort.

Methods: 88 CD patients who had abdominal CT scans during hospitalization were retrospectively enrolled. The skeletal muscle index (SMI) at the third lumbar vertebra level was used to assess sarcopenia. Sarcopenia was defined as a SMI <38.5 cm/m in women, <52.4 cm/m in men and visceral obesity as a visceral fat area ≥130 cm. Clinical malnutrition was defined by a BMI <18.5 kg/m. Univariate analysis was performed, and predictors for surgery in the follow-up were entered in a stepwise logistic regression model for multivariate analysis.

Results: The prevalence of sarcopenia was 58%, malnutrition 21.6%, and visceral obesity 19.3%. Among sarcopenic patients, 49% had a normal BMI, 13.7% were overweight, and 1(2%) was obese. Sarcopenic CD patients had significantly more abscesses (51% vs 16.7%, p = 0.001), hospitalizations (61.2% vs 36.1%, p = 0.022) and digestive surgery (63.3% vs 27.8%, p = 0.001) than non-sarcopenic patients during the follow-up, whereas usual malnutrition assessment was not correlated with disease outcomes. In multivariate analysis, both sarcopenia and visceral obesity were associated with further occurrence of digestive surgery.

Conclusion: Both sarcopenia and visceral obesity were associated with adverse outcomes in severe CD patients whereas usual nutritional assessment was not.
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http://dx.doi.org/10.1016/j.clnu.2020.01.001DOI Listing
October 2020

Severe leptospirosis in non-tropical areas: a nationwide, multicentre, retrospective study in French ICUs.

Intensive Care Med 2019 12 25;45(12):1763-1773. Epub 2019 Oct 25.

Service de Médecine Intensive Réanimation, Centre Hospitalier Henri Duffaut, Avignon, France.

Purpose: To report the incidence, risk factors, clinical presentation, and outcome predictors of severe leptospirosis requiring intensive care unit (ICU) admission in a temperate zone.

Methods: LEPTOREA was a retrospective multicentre study conducted in 79 ICUs in metropolitan France. Consecutive adults admitted to the ICU for proven severe leptospirosis from January 2012 to September 2016 were included. Multiple correspondence analysis (MCA) and hierarchical classification on principal components (HCPC) were performed to distinguish different clinical phenotypes.

Results: The 160 included patients (0.04% of all ICU admissions) had median values of 54 years [38-65] for age, 40 [28-58] for the SAPSII, and 11 [8-14] for the SOFA score. Hospital mortality was 9% and was associated with older age; worse SOFA score and early need for endotracheal ventilation and/or renal replacement therapy; chronic alcohol abuse and worse hepatic dysfunction; confusion; and higher leucocyte count. Four phenotypes were identified: moderately severe leptospirosis (n = 34, 21%) with less organ failure and better outcomes; hepato-renal leptospirosis (n = 101, 63%) with prominent liver and kidney dysfunction; neurological leptospirosis (n = 8, 5%) with the most severe organ failures and highest mortality; and respiratory leptospirosis (n = 17, 11%) with pulmonary haemorrhage. The main risk factors for leptospirosis contamination were contact with animals, contact with river or lake water, and specific occupations.

Conclusions: Severe leptospirosis was an uncommon reason for ICU admission in metropolitan France and carried a lower mortality rate than expected based on the high severity and organ-failure scores. The identification in our population of several clinical presentations may help clinicians establish an appropriate index of suspicion for severe leptospirosis.
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http://dx.doi.org/10.1007/s00134-019-05808-6DOI Listing
December 2019

Air in the Heart? Check the Liver.

Am J Respir Crit Care Med 2020 Apr;201(8):995

Medical Intensive Care Unit and.

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http://dx.doi.org/10.1164/rccm.201908-1507IMDOI Listing
April 2020

Transmural Bowel Necrosis From Acute Mesenteric Ischemia and Strangulated Small-Bowel Obstruction: Distinctive CT Features.

AJR Am J Roentgenol 2020 01 25;214(1):90-95. Epub 2019 Sep 25.

Service de Radiologie, CHU Besançon, 3 Blvd Fleming, Besançon, France 25000.

The purpose of this study was to assess whether transmural bowel necrosis has distinct CT features based on the three main causes: occlusive acute mesenteric ischemia (AMI), nonocclusive AMI, and strangulated small-bowel obstruction (SBO). From January 2010 to December 2017, the records of all patients with a pathologic diagnosis of transmural bowel necrosis were extracted from the pathology department database of a university hospital. The inclusion criteria for the study were presence of transmural bowel necrosis at pathologic examination and available contrast-enhanced CT images obtained within the 24 hours before surgery. Seventy-seven patients were finally included. The CT scans were retrospectively independently reviewed by two abdominal radiologists to identify the classic CT findings of transmural bowel necrosis. Statistical analyses were performed. Pneumatosis intestinalis was statistically more frequent in nonocclusive AMI (59%) than in occlusive AMI (29%) and strangulated SBO (7%) ( < 0.01), as were superior mesenteric venous gas (55%, 29%, and 0%; < 0.01) and portal venous gas (48%, 10%, and 0%; < 0.01). Decreased or absent bowel wall enhancement was more frequent in AMI than in SBO (nonocclusive AMI, 83%; occlusive AMI, 81%; SBO, 56%; = 0.02), as was thinned bowel wall (nonocclusive AMI, 52%; occlusive AMI, 48%; SBO, 18%; = 0.02). Spontaneous hyperattenuation of the bowel wall was more frequent in strangulated SBO (41%) than in nonocclusive AMI (10%) and occlusive AMI (14%) ( < 0.01). Transmural bowel necrosis has distinct CT findings according to its three main causes. Occlusive AMI is characterized by an absence of bowel wall enhancement and less mesenteric fat stranding, nonocclusive AMI by a high prevalence of pneumatosis intestinalis and portal venous gas, and strangulated SBO by spontaneous hyperattenuation of the bowel wall and an absence of pneumatosis intestinalis and portal venous gas.
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http://dx.doi.org/10.2214/AJR.19.21693DOI Listing
January 2020

Dose of enteral nutrition and enterocyte biomarker: a circular link?

Intensive Care Med 2019 09 23;45(9):1325. Epub 2019 Jul 23.

CHU de Nantes, Médecine Intensive Réanimation, Nantes, France.

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http://dx.doi.org/10.1007/s00134-019-05697-9DOI Listing
September 2019

Trisodium citrate 4% versus heparin as a catheter lock for non-tunneled hemodialysis catheters in critically ill patients: a multicenter, randomized clinical trial.

Ann Intensive Care 2019 Jul 1;9(1):75. Epub 2019 Jul 1.

CH de Bourg en Bresse, Service de Réanimation polyvalente, 01000, Bourg en Bresse, France.

Background: Non-tunneled hemodialysis catheters are currently used for critically ill patients with acute kidney injury requiring extracorporeal renal replacement therapy. Strategies to prevent catheter dysfunction and infection with catheter locks remain controversial.

Methods: In a multicenter, randomized, controlled, double-blind trial, we compared two strategies for catheter locking of non-tunneled hemodialysis catheters, namely trisodium citrate at 4% (intervention group) versus unfractionated heparin (control group), in patients aged 18 years or older admitted to the intensive care unit and in whom a first non-tunneled hemodialysis catheter was to be inserted by the jugular or femoral vein. The primary endpoint was length of event-free survival of the first non-tunneled hemodialysis catheter. Secondary endpoints were: rate of fibrinolysis, incidence of catheter dysfunction and incidence of catheter-related bloodstream infection (CRBSI), all per 1000 catheter-days; number of hemorrhagic events requiring transfusion, length of stay in intensive care and in hospital; 28-day mortality.

Results: Overall, 396 randomized patients completed the trial: 199 in the citrate group and 197 in the heparin group. There was no significant difference in baseline characteristics between groups. The duration of event-free survival of the first non-tunneled hemodialysis catheter was not significantly different between groups: 7 days (IQR 3-10) in the citrate group and 5 days (IQR 3-11) in the heparin group (p = 0.51). Rates of catheter thrombosis, CRBSI, and adverse events were not statistically different between groups.

Conclusions: In critically ill patients, there was no significant difference in the duration of event-free survival of the first non-tunneled hemodialysis catheter between trisodium citrate 4% and heparin as a locking solution. Catheter thrombosis, catheter-related infection, and adverse events were not statistically different between the two groups. Trial registration Registered with Clinicaltrials.gov under the number NCT01962116. Registered 14 October 2013.
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http://dx.doi.org/10.1186/s13613-019-0553-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603108PMC
July 2019
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