Blot S.,Ghent University |
Charles P.-E.,Service de Reanimation Medicale
Minerva Anestesiologica | Year: 2013
Despite the availability of broad-spectrum antifungal agents, fungal sepsis remains an issue in Intensive Care Unit (ICU) patients. In terms of occurrence rates, the most important fungal infections are invasive candidiasis and invasive pulmonary aspergillosis. Early diagnosis is essential to optimize the chances of survival. As clinical rules based on risk factor assessment lack specificity, early initiation of antifungal therapy depends on fast and reliable diagnostics. Blood cultures or histopathologic evidence is the gold standard but blood cultures lack sensitivity and biopsy sampling may include substantial risk in critically ill patients. Non-culture-based diagnosis tools have therefore arisen as a smart way to detect earlier and/or more accurately the patients with on going fungal infection. For diagnosing invasive candidiasis, three assays (beta-D-glucan and mannan antigen detection, and polymerase chain reaction) yield promising predictive values, albeit that specificity remains an issue. In the absence of biopsies, invasive pulmonary aspergillosis can be diagnosed in nonneutropenic ICU patients by galactomannan antigen detection in broncho-alveolar lavage fluid. Aspergillus colonization of the respiratory tract can be discriminated from invasive disease by means of a clinical algorithm with high sensitivity but only moderate specificity. The incidence of invasive candidiasis has been stable over the past decades, but an alarming trend towards more non-albicans Candida species and reduced susceptibility is observed. Given the problematic diagnosis of invasive aspergillosis no reliable trend data are available. Outcome following fungal sepsis remains cumbersome. Given the availability of potent antifungal agents any progress in survival is likely to come from a more timely diagnosis.
Soumagne N.,Service de Reanimation Medicale
The American journal of emergency medicine | Year: 2011
Taxine, a yew tree toxin, is highly cardiotoxic. We report the case of a patient who developed severe cardiac failure and ventricular fibrillation after consuming yew leaves and who made a full recovery after extracorporeal life support. Yew poisoning can be added to the list of potential indications of extracorporeal life support for refractory toxic cardiogenic shock.
Lichtenstein D.A.,Service de Reanimation Medicale
Medical Ultrasonography | Year: 2014
The most critical application of critical ultrasound - cardiac arrest - is the opportunity for technical considerations. The necessity to immediately detect reversible causes is integrated in the concept of holistic ultrasound. Holistic ultrasound is defined as a discipline where each element interacts with the others, and where the understanding of each of them allows understanding the whole. A narrow machine (not necessarily a laptop), a fast start-on time, a simple keyboard highlighting three useful buttons, a universal microconvex probe able to immediately detect pneumothorax, then deep venous thrombosis, then abdominal bleeding, then pericardial tamponade, then cardiac anomalies will allow a fast protocol. The concept of holistic ultrasound is particularly on focus in the first step done at the lung (search for pneumothorax and clearance for fluid therapy), since the best image is obtained with the simplest equipment devoid of traditional facilities (image filtering, harmonics, time lag, Doppler...). The same simple gray-scale equipment is used for the other steps, all what is needed is to see the real-time image of what is facing the probe: the very principle of visual medicine. The same approach can be used with no change, just more quietly, for many less urgent settings.
Savalle M.,Service de Reanimation Medicale
American journal of physiology. Endocrinology and metabolism | Year: 2012
Critical illness affects body composition profoundly, especially body cell mass (BCM). BCM loss reflects lean tissue wasting and could be a nutritional marker in critically ill patients. However, BCM assessment with usual isotopic or tracer methods is impractical in intensive care units (ICUs). We aimed to modelize the BCM of critically ill patients using variables available at bedside. Fat-free mass (FFM), bone mineral (Mo), and extracellular water (ECW) of 49 critically ill patients were measured prospectively by dual-energy X-ray absorptiometry and multifrequency bioimpedance. BCM was estimated according to the four-compartment cellular level: BCM = FFM - (ECW/0.98) - (0.73 × Mo). Variables that might influence the BCM were assessed, and multivariable analysis using fractional polynomials was conducted to determine the relations between BCM and these data. Bootstrap resampling was then used to estimate the most stable model predicting BCM. BCM was 22.7 ± 5.4 kg. The most frequent model included height (cm), leg circumference (cm), weight shift (Δ) between ICU admission and body composition assessment (kg), and trunk length (cm) as a linear function: BCM (kg) = 0.266 × height + 0.287 × leg circumference + 0.305 × Δweight - 0.406 × trunk length - 13.52. The fraction of variance explained by this model (adjusted r(2)) was 46%. Including bioelectrical impedance analysis variables in the model did not improve BCM prediction. In summary, our results suggest that BCM can be estimated at bedside, with an error lower than ±20% in 90% subjects, on the basis of static (height, trunk length), less stable (leg circumference), and dynamic biometric variables (Δweight) for critically ill patients.
Lichtenstein D.,Service de Reanimation Medicale
Expert Review of Respiratory Medicine | Year: 2012
The FALLS-protocol is included in a limited investigation to diagnose the cause of shock. After simple echocardiography has ruled out obstructive shock (tamponade, pulmonary embolism), the lung is investigated. Absence of disseminated lung rockets rules out cardiogenic shock. At this point, hypovolemic and septic shock are differential diagnoses (rarities apart), and the FALLS-protocol provides fluid therapy with constant monitoring of lung artifacts. Hypovolemic shock will eventually improve - septic shock will not, and the slight excess fluid creates an early, silent stage of interstitial edema, demonstrated by B-lines, demanding interruption of fluid therapy. This sequential approach, combined with the usual, clinical, biochemical and echocardiographic parameters, must be evaluated in multicenter studies. © 2012 Expert Reviews Ltd.
Coudroy R.,Service de Reanimation Medicale
Shock | Year: 2016
ABSTRACT: Conflicting results have been reported on the influence of Polymyxin-B hemoperfusion treatment on systemic inflammation markers. The aim of study was to assess in a randomized control trial the influence on plasma cytokine concentrations of Polymyxin-B hemoperfusion in septic shock due to peritonitis. A panel of 10 pro- or anti-inflammatory cytokines was measured in 213 patients with peritonitis-induced septic shock enrolled in the randomized trial ABDOMIX testing the impact of 2 Polymyxin-B hemoperfusion sessions with standard treatment. Gram negative bacteria were identified in 69% of patients. In the overall population, baseline plasma cytokine concentrations were not different between the 2 groups. Circulating TNF-α, IL-1β, IL-10, IL-6 and IL-1RA decreased significantly over time in both groups (p?0.0001 for all in controls, and p?=?0.0002, 0.003 and <0.0001 in patients treated with Polymyxin-B hemoperfusion). IL-17A decreased significantly in patients treated with Polymyxin B hemoperfusion (p?=?0.045) but not in controls. At the end of the second Polymyxin-B hemoperfusion session or at corresponding time in controls, plasma levels of cytokines did not differ between the 2 groups. Similar results were found in the subgroup of patients with Gram negative peritonitis who completed 2 Polymyxin-B hemoperfusion sessions. These results do not support a significant influence of Polymyxin-B hemoperfusion on circulating cytokines assessed except for IL-17A which clinical significance remains to be elucidated. © 2016 by the Shock Society
Afessa B.,Rochester College |
Azoulay E.,Service de Reanimation Medicale
Critical Care Clinics | Year: 2010
An estimated 50,000 to 60,000 patients undergo hematopoietic stem cell transplantation (HSCT) worldwide annually, of which 15.7% are admitted to the intensive care unit (ICU). The most common reason for ICU admission is respiratory failure and almost all develop single or multiorgan failure. Most HSCT recipients admitted to ICU receive invasive mechanical ventilation (MV). The overall short-term mortality rate of HSCT recipients admitted to ICU is 65%, and 86.4% for those receiving MV. Patient outcome has improved over time. Poor prognostic indicators include advanced age, poor functional status, active disease at transplant, allogeneic transplant, the severity of acute illness, and the development of multiorgan failure. ICU resource limitations often lead to triage decisions for admission. For HSCT recipients, the authors recommend (1) ICU admission for full support during their pre-engraftment period and when there is no evidence of disease recurrence; (2) no ICU admission for patients who refuse it and those who are bedridden with disease recurrence and without treatment options except palliation; (3) a trial ICU admission for patients with unknown status of disease recurrence with available treatment options. © 2010 Elsevier Inc. All rights reserved.
Derive M.,Service de Reanimation Medicale |
Gibot S.,Service de Reanimation Medicale
Critical Care | Year: 2011
The triggering receptor expressed on myeloid cells-1 (TREM-1) is an immunoreceptor whose role is to amplify the inflammatory response mediated by the engagement of Toll-like and NOD-like receptors. As the expression of TREM-1 is believed to be upregulated during infection, this protein has been studied as a sepsis biomarker. In the previous issue of Critical Care, Su and colleagues reported on the usefulness of urinary soluble TREM-1 in diagnosing sepsis and assessingits severity. Importantly, the authors describe, for the first time, that urinary soluble TREM-1 measurement is able to predict the development of sepsis-associated acute kidney injury (AKI). If these results were to be confirmed by larger studies, urinary soluble TREM-1 would possibly become a new biomarker for sepsis-associated AKI. © 2011 BioMed Central Ltd.
Lichtenstein D.A.,Service de Reanimation Medicale
Chest | Year: 2015
This review article describes two protocols adapted from lung ultrasound: the bedside lung ultrasound in emergency (BLUE)-protocol for the immediate diagnosis of acute respiratory failure and the fluid administration limited by lung sonography (FALLS)-protocol for the management of acute circulatory failure. These applications require the mastery of 10 signs indicating normal lung surface (bat sign, lung sliding, A-lines), pleural effusions (quad and sinusoid sign), lung consolidations (fractal and tissue-like sign), interstitial syndrome (lung rockets), and pneumothorax (stratosphere sign and the lung point). These signs have been assessed in adults, with diagnostic accuracies ranging from 90% to 100%, allowing consideration of ultrasound as a reasonable bedside gold standard. In the BLUE-protocol, profiles have been designed for the main diseases (pneumonia, congestive heart failure, COPD, asthma, pulmonary embolism, pneumothorax), with an accuracy > 90%. In the FALLS-protocol, the change from A-lines to lung rockets appears at a threshold of 18 mm Hg of pulmonary artery occlusion pressure, providing a direct biomarker of clinical volemia. The FALLS-protocol sequentially rules out obstructive, then cardiogenic, then hypovolemic shock for expediting the diagnosis of distributive (usually septic) shock. These applications can be done using simple grayscale machines and one microconvex probe suitable for the whole body. Lung ultrasound is a multifaceted tool also useful for decreasing radiation doses (of interest in neonates where the lung signatures are similar to those in adults), from ARDS to trauma management, and from ICUs to points of care. If done in suitable centers, training is the least of the limitations for making use of this kind of visual medicine. © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS.
Lichtenstein D.,Service de Reanimation Medicale
Current Opinion in Critical Care | Year: 2014
Purpose of Review: Lung ultrasound, which allows a bedside visualization of the lungs, is increasingly used in critical care. This review aims at highlighting a simple approach to this new discipline. Recent Findings: The 10 basic signs are the bat sign (indicating pleural line), lung sliding (yielding the seashore sign), the A line (horizontal artifact), the quad and sinusoid sign indicating pleural effusion regardless of its echogenicity, the tissue-like and shred sign indicating lung consolidation, the B line and lung rockets (artifacts indicating interstitial syndrome), abolished lung sliding with the stratosphere sign, suggesting pneumothorax, and the lung point, indicating pneumothorax. All these disorders were assessed using computed tomography (CT) as a gold standard with sensitivity and specificity ranging from 90 to 100%, allowing us to consider ultrasound as a reasonable bedside gold standard in the critically ill. We use a simple gray-scale unit (without Doppler) with a microconvex probe. Summary: Lung ultrasound can be used for diagnosing acute respiratory failure (BLUE protocol), managing acute circulatory failure (Fluid Administration Limited by Lung Sonography protocol), and decreasing the use of radiograph or CT (the Lung Ultrasound in the Critically Ill Favoring Limitation of Radiation project). This can be extended from sophisticated ICUs to more austere settings, from neonates to bariatric adults without adaptation, trauma and several other disciplines (anesthesiology, emergency medicine, pulmonology, etc.). © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.