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ABSTRACT: Cirrhosis of the liver is associated with an increased susceptibility to bacterial infections capable of causing septic shock and with a basal hyperdynamic circulatory state. The primary objective of this study was to delineate the echocardiographic characteristics and outcomes of septic shock in patients with liver cirrhosis. The secondary objective was to determine whether adrenal insufficiency, which may contribute to hyperdynamic syndrome, was more marked in patients with cirrhosis than in other patients with septic shock.
Prospective single-center cohort study.
Thirty-four patients admitted to the intensive care unit (ICU) for septic shocks were included, 14 with and 20 without liver cirrhosis. Echocardiography was performed within the first 24 h to measure the cardiac index (CI), systolic index (SI), and left ventricular ejection fraction (LVEF). A Synacthen test was performed.
Patients with cirrhosis had higher values for the CI (3.69+/-1.0 vs. 2.86+/-0.8 l/min/m(2); P=0.02), SI (37.5+/-8 vs. 32.4+/-7 ml/m(2); P=0.04), and LVEF (67+/-7 vs. 55.9+/-12%; P=0.005). ICU mortality was 53% overall, 64% in patients with cirrhosis, and 45% in patients without cirrhosis (P=0.27). Serum cortisol levels under basal conditions (H0) and after stimulation (H1) showed no significant differences between patients with and without cirrhosis. The proportion of patients with no response to Synacthen was 77% among patients with cirrhosis and 50% among patients without cirrhosis (P=0.18).
In a population with septic shock, left ventricular function was more hyperdynamic in the subset with cirrhosis. Relative adrenal insufficiency occurred in similar proportions of patients with and without cirrhosis.
Acta Anaesthesiologica Scandinavica 02/2008; 52(1):45-51. · 2.19 Impact Factor
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Endoscopy 03/2007; 39 Suppl 1:E96. · 5.21 Impact Factor
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ABSTRACT: A 43-year-old man with chronic alcohol pancreatitis was admitted in our intensive care unit for an haemorrhagic shock. An abdominal CT-scan performed on admission showed bleeding from a vessel in a pancreatic pseudocyst. Initial treatment included intravenous fluids, transfusion, mechanical ventilation and vasopressive support. Percutaneous arterial embolization (PAE) of a bleeding right superior colon artery was performed with an initial good result. Nevertheless after initial clinical improvement, hypotension refractory to fluid management occurred. An abdominal CT-scan disclosed pneumatosis in right colon. A right hemicolectomy was performed. Histologic analysis confirmed ischemic colitis. The patient recovered and was discharged from the intensive care unit. Colitis necrosis after PAE for pancreatic pseudoaneurysm had never been described before. It should be suspected when haemodynamic instability occurs following PAE.
Annales francaises d'anesthesie et de reanimation 03/2007; 26(2):161-3. · 0.77 Impact Factor
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ABSTRACT: The aim of this study was to evaluate the accuracy of the BNP as a marker of acute cor pulmonale in patients with ARDS.
Prospective clinical trial.
At day 2 or 3 after the onset of the ARDS, an echocardiography was performed. Patients with left ventricular dysfunction were excluded. Right ventricular area (RVA) and RVA/LVA ratio were measured. ACP was defined as RVA/LVA > 0.6 associated with septal dyskinesia. Simultaneously, 5 ml of blood was collected for BNP measurement.
26 patients were studied. BNP levels were higher in 10 patients with ACP: 585.5 [189-4830] vs 145.5 [36.5-346] pg/ml (P=0.01) but in those with creatinine clearance < 90 ml/min: 602 [331-3530] vs 125 [39-189] pg/ml (P=0.007). BNP was correlated with RVA (r=0.5; p=0.01), RVA/LVA ratio (r=0.61; p=0.001), sPAP (r=0.58; p=0.002) and with age, cardiac index and creatinine clearance (r=0.61; p=0.001). In multivariate analysis, BNP was only correlated with creatinine clearance (p=0.03), and RVA (p=0.06).
In ARDS patients without left ventricular dysfunction, BNP level is more elevated in patients with acute cor pulmonale than patients without cor pulmonale.
Annales Françaises d Anesthésie et de Réanimation 08/2006; 25(8):815-9. · 0.84 Impact Factor
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ABSTRACT: Plasma B-type natriuretic peptide (BNP) assay is recommended as a diagnostic tool in emergency-room patients with acute dyspnea. In the intensive care unit (ICU), the utility of this peptide remains a matter of debate. The objectives of this study were to determine whether cut-off values for BNP and N-terminal-proBNP (NT-proBNP) reliably diagnosed right and/or left ventricular failure in patients with shock or acute respiratory distress, and whether non-cardiac factors led to an increase in these markers.
Plasma BNP and NT-proBNP levels and echocardiographic parameters of cardiac dysfunction were determined in 41 patients within 24 h of the onset of shock or acute respiratory distress.
BNP and NT-proBNP levels were higher in the 25 patients with heart failure than in the other 16 patients: 491.7 +/- 418 pg/ml vs. 144.3 +/- 128 pg/ml and 2874.4 +/- 2929 pg/ml vs. 762.7 +/- 1128 pg/ml, respectively (P < 0.05). In the diagnosis of cardiac dysfunction, BNP > 221 pg/ml and NT-proBNP > 443 pg/ml had 68% and 84% sensitivity, respectively, and 88% and 75% specificity, respectively, but there was a substantial overlap of BNP and NT-proBNP values between patients with and without heart failure. BNP and NT-proBNP were elevated, but not significantly, in patients with isolated right ventricular dysfunction. Patients with renal dysfunction and normal heart function had significantly higher levels of BNP (258.6 +/- 144 pg/ml vs. 92.4 +/- 84 pg/ml) and NT-proBNP (2049 +/- 1320 pg/ml vs. 118 +/- 104 pg/ml) than patients without renal dysfunction.
Both BNP and NT-proBNP can help in the diagnosis of cardiac dysfunction in ICU patients, but cannot replace echocardiography. An elevated BNP or NT-proBNP level merely indicates the presence of a 'cardiorenal distress' and should prompt further investigation.
Acta Anaesthesiologica Scandinavica 04/2006; 50(3):340-7. · 2.19 Impact Factor
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ABSTRACT: The aim of this study was to evaluate the accuracy of the combined index E/Vp (peak E velocity combined with color M-mode color Doppler flow propagation) for estimating pulmonary capillary wedge pressure, in post cardiac surgery patients.
Prospective clinical trial.
In post cardiac surgery patients (D1), we have measured with transthoracic echocardiography peak early E transmitral pulsed Doppler velocities and color M-mode Doppler flow propagation velocity (Vp). The E/Vp ratio was compared with pulmonary capillary wedge pressure (PAPO) obtained simultaneously.
Thirty eight patients were studied. The coefficient of correlation between PAPO and E/Vp was r = 0.71 (p < 0.0001). The sensitivity and the specificity of E/Vp > 1.5 for prediction of PAPO > 15 mmHg were 79% and 79% respectively.
In post cardiac surgery patients, PAPO can be reasonably estimated by measuring the ratio E/Vp obtained with Doppler echocardiography.
Annales Françaises d Anesthésie et de Réanimation 09/2004; 23(9):873-8. · 0.84 Impact Factor
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ABSTRACT: Pulse oximetry (SpO2) is a standard monitoring device in intensive care units (ICUs), currently used to guide therapeutic interventions. Few studies have evaluated the accuracy of SpO2 in critically ill patients. Our objective was to compare pulse oximetry with arterial oxygen saturation (SaO2) in such patients, and to examine the effect of several factors on this relationship.
Observational prospective study.
A 26-bed medical ICU in a university hospital.
One hundred two consecutive patients admitted to the ICU in whom one or serial arterial blood gas analyses (ABGs) were performed and a reliable pulse oximeter signal was present.
For each ABG, we collected SaO2, SpO2, the type of pulse oximeter, the mode of ventilation and requirement for vasoactive drugs.
Three hundred twenty-three data points were collected. The mean difference between SpO2 and SaO2 was -0.02% and standard deviation of the differences was 2.1%. From one sample to another, the fluctuations in SpO2 to arterial saturation difference indicated that SaO2 could not be reliably predicted from SpO2 after a single ABG. Subgroup analysis showed that the accuracy of SpO2 appeared to be influenced by the type of oximeter, the presence of hypoxemia and the requirement for vasoactive drugs. Finally, high SpO2 thresholds were necessary to detect significant hypoxemia with good sensitivity.
Large SpO2 to SaO2 differences may occur in critically ill patients with poor reproducibility of SpO2. A SpO2 above 94% appears necessary to ensure a SaO2 of 90%.
Intensive Care Medicine 11/2001; 27(10):1606-13. · 5.40 Impact Factor
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ABSTRACT: We evaluated whether tumor necrosis factor (TNF)-alpha induces an increase in permeability of an alveolar epithelial monolayer via gelatinase secretion and basement membrane degradation. Gelatinase secretion and epithelial permeability to radiolabeled albumin under unstimulated and TNF-alpha-stimulated conditions of an A549 human epithelial cell line were evaluated in vitro. TNF-alpha induced both upregulation of a 92-kDa gelatinolytic activity (pro form in cell supernatant and activated form in extracellular matrix) and an increase in the epithelial permeability coefficient compared with the unstimulated condition (control: 1.34 +/- 0.04 x 10(-6) cm/s; 1 microg/ml TNF-alpha: 1.47 +/- 0.05 x 10(-6) cm/s, P < 0.05). The permeability increase in the TNF-alpha-stimulated condition involved both paracellular permeability, with gap formation visualized by actin cytoskeleton staining, and basement membrane permeability, with an increase in the basement membrane permeability coefficient (determined after cell removal; control: 2.58 +/- 0.07 x 10(-6) cm/s; 1 microg/ml TNF-alpha: 2.82 +/- 0.02.10(-6) x cm/s, P < 0.05). Because addition of gelatinase inhibitors [tissue inhibitor of metalloproteinase (TIMP)-1 or BB-3103] to cell supernatants failed to inhibit the permeability increase, the gelatinase-inhibitor balance in the cellular microenvironment was further evaluated by cell culture on a radiolabeled collagen matrix. In the unstimulated condition, spontaneous collagenolytic activity inhibited by addition to the matrix of 1 microg/ml TIMP-1 or 10(-6) M BB-3103 was found. TNF-alpha failed to increase this collagenolytic activity because it was associated with dose-dependent upregulation of TIMP-1 secretion by alveolar epithelial cells. In conclusion, induction by TNF-alpha of upregulation of both the 92-kDa gelatinase and its inhibitor TIMP-1 results in maintenance of the gelatinase-inhibitor balance, indicating that basement membrane degradation does not mediate the TNF-alpha-induced increase in alveolar epithelial monolayer permeability.
AJP Lung Cellular and Molecular Physiology 07/2001; 281(1):L134-43. · 3.66 Impact Factor
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ABSTRACT: To assess the feasibility of exhaled carbon monoxide (CO) measurements in mechanically ventilated critically ill adult patients and to determine the influence of inspired oxygen fraction on this measurement.
Prospective physiologic study.
Medical ICU in a community hospital.
The study was performed on nine mechanically ventilated patients with varying diagnoses.
Carbon monoxide concentration was determined with an infrared CO analyzer on exhaled breath collected at the outlet of the ventilator. We assessed the stability of exhaled carbon monoxide concentration over a 4-hour period and determined its course during a 7-hour period after inspired oxygen fraction had been abruptly increased from baseline to 1. Carbon monoxide was detected in exhaled breath in each patient at a higher concentration than in inspired gas (0.64 +/- 0.1 ppm vs 0.25 ppm, approximately). Exhaled carbon monoxide did not vary during a 4-hour period in five hemodynamically stable patients. When inspired oxygen fraction was increased from baseline (0.52 +/- 0.04) to 1, exhaled carbon monoxide concentration increased abruptly from baseline (0.63 +/- 0.13 ppm) to a peak value of 1.54 +/- 0.16 ppm within 15 min and returned slowly to baseline values within 7 h.
CO was easily detected in the exhaled breath of mechanically ventilated patients and CO lung excretion was markedly but transiently dependent on inspired oxygen fraction. Other studies are warranted in order to determine the different factors that might influence CO lung excretion in critically ill patients.
Intensive Care Medicine 10/2000; 26(9):1228-31. · 5.40 Impact Factor
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