[Show abstract][Hide abstract] ABSTRACT: Although sudden cardiac death has been broadly studied, little is known on cerebrovascular events revealed by out-of-hospital cardiac arrest. We aimed to describe clinical features and prognosis of these patients and identify characteristics that could suggest a cerebrovascular etiology of the out-of-hospital cardiac arrest.
Retrospective review (1999-2012) of databases of three regional referral ICU centers for out-of-hospital cardiac arrest.
Patients admitted to ICU for management of successfully resuscitated out-of-hospital cardiac arrest.
Patients were included when subarachnoid hemorrhage, intracranial hemorrhage, ischemic stroke, sub/epidural hematoma, or cerebral thrombophlebitis was identified as the primary cause of out-of-hospital cardiac arrest. Traumatic or infectious causes were excluded. Patients were compared with a group of out-of-hospital cardiac arrest of nonneurological origin.
All medical records of the three prospective ICU databases, registered according to the Utstein style, were reviewed.
Among 3,710 patients admitted for out-of-hospital cardiac arrest, 86 were included (mainly subarachnoid hemorrhage, n = 73). Prodromes were mostly neurological but falsely evoked a cardiac origin in six patients. Electrocardiogram displayed abnormalities in 64% of patients, with 23% of pseudoischemic pattern (ST-segment elevation or left bundle branch block). Mortality rate was 100%, with brain death as the leading cause. In comparison with the nonneurological out-of-hospital cardiac arrest group, female gender, onset of neurological prodromes, lack of other prodromes, initial nonshockable rhythm, and unspecific electrocardiogram repolarization abnormalities were independent predictive factors of a primary cerebrovascular etiology. When present, the combination of these elements displayed an area under the receiver operating characteristic curve of 0.86 (95% CI, 0.81-0.91).
Presentation of cerebrovascular event complicated with out-of-hospital cardiac arrest may mimic coronary etiology, but several clinical elements may help to identify brain causes. Even if survival is null, the high proportion of brain deaths provides opportunity for organ donation.
[Show abstract][Hide abstract] ABSTRACT: The availability of circulating biomarkers that helps to identify early out-of-hospital cardiac arrest survivors who are at increased risk of long-term mortality remains challenging. Our aim was to prospectively study the association between copeptin and 1-year mortality in patients with out-of-hospital cardiac arrest admitted in a tertiary cardiac arrest center.
Retrospective monocenter study.
Tertiary cardiac arrest center in Paris, France.
Copeptin was assessed at admission and day 3. Pre- and intrahospital factors associated with 1-year mortality were analyzed by multivariate Cox proportional analysis.
Two hundred ninety-eight consecutive out-of-hospital cardiac arrest patients (70.3% male; median age, 60.2 yr [49.9-71.4]) were admitted in a tertiary cardiac arrest center in Paris (France). After multivariate analysis, higher admission copeptin was associated with 1-year mortality with a threshold effect (hazard ratio5th vs 1st quintile = 1.64; 95% CI, 1.05-2.58; p = 0.03). Day 3 copeptin was associated with 1-year mortality in a dose-dependent manner (hazard ratio2nd vs 1st quintile = 1.87; 95% CI, 1.00-3.49; p = 0.05; hazard ratio3rd vs 1st quintile = 1.92; 95% CI, 1.02-3.64; p = 0.04; hazard ratio4th vs 1st quintile = 2.12; 95% CI, 1.14-3.93; p = 0.02; and hazard ratio5th vs 1st quintile = 2.75; 95% CI, 1.47-5.15; p < 0.01; p for trend < 0.01). For both admission and day 3 copeptin, association with 1-year mortality existed for out-of-hospital cardiac arrest of cardiac origin only (p for interaction = 0.05 and < 0.01, respectively). When admission and day 3 copeptin were mutually adjusted, only day 3 copeptin remained associated with 1-year mortality in a dose-dependent manner (p for trend = 0.01).
High levels of copeptin were associated with 1-year mortality independently from prehospital and intrahospital risk factors, especially in out-of-hospital cardiac arrest of cardiac origin. Day 3 copeptin was superior to admission copeptin: this could permit identification of out-of-hospital cardiac arrest survivors at increased risk of mortality and allow for close observation of such patients.
[Show abstract][Hide abstract] ABSTRACT: The prognosis of critically ill cancer patients has improved recently. Controversies remain as regard to the specific prognosis impact of neutropenia in critically ill cancer patients. The primary objective of this study was to assess hospital outcome of critically ill neutropenic cancer patients admitted into the ICU. The secondary objective was to assess risk factors for unfavorable outcome in this population of patients and specific impact of neutropenia.
We performed a post hoc analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centers in France and Belgium. Neutropenia was defined as a neutrophil count lower than 500/mm(3).
Among the 1,011 patients admitted into the ICU during the study period 289 were neutropenic at the time of admission. Overall, 131 patients died during their hospital stay (hospital mortality 45.3 %). Four variables were associated with a poor outcome, namely allogeneic transplantation (OR 3.83; 95 % CI 1.75-8.35), need for mechanical ventilation (MV) (OR 6.57; 95 % CI 3.51-12.32), microbiological documentation (OR 2.33; CI 1.27-4.26), and need for renal replacement therapy (OR 2.77; 95 % CI 1.34-5.74). Two variables were associated with hospital survival, namely age younger than 70 (OR 0.22; 95 % CI 0.1-0.52) and neutropenic enterocolitis (OR 0.37; 95 % CI 0.15-0.9). A case-control analysis was also performed with patients of the initial database; after adjustment, neutropenia was not associated with hospital mortality (OR 1.27; 95 % CI 0.86-1.89).
Hospital survival was closely associated with younger age and neutropenic enterocolitis. Conversely, need for conventional MV, for renal replacement therapy, and allogeneic hematopoietic stem cell transplantation (HSCT) were associated with poor outcome.
Intensive Care Medicine 01/2015; 41(2). · 5.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Cardiac involvement is a major cause of mortality in patients with thrombotic thrombocytopenic purpura (TTP). However, diagnosis remains underestimated and delayed, owing to subclinical injuries. Cardiac troponin-I measurement (cTnI) on admission could improve the early diagnosis of cardiac involvement and have prognostic value.Objectives
To assess the predictive value of cTnI in patients with TTP for death or refractoriness.Patients/Methods
The study involved a prospective cohort of adult TTP patients with acquired severe ADAMTS-13 deficiency (< 10%) and included in the registry of the French Reference Center for Thrombotic Microangiopathies. Centralized cTnI measurements were performed on frozen serum on admission.ResultsBetween January 2003 and December 2011, 133 patients with TTP (mean age, 48 ± 17 years) had available cTnI measurements on admission. Thirty-two patients (24%) had clinical and/or electrocardiogram features. Nineteen (14.3%) had cardiac symptoms, mainly congestive heart failure and myocardial infarction. Electrocardiogram changes, mainly repolarization disorders, were present in 13 cases. An increased cTnI level (> 0.1 μg L−1) was present in 78 patients (59%), of whom 46 (59%) had no clinical cardiac involvement. The main outcomes were death (25%) and refractoriness (17%). Age (P = 0.02) and cTnI level (P = 0.002) showed the greatest impact on survival. A cTnI level of > 0.25 μg L−1 was the only independent factor in predicting death (odds ratio [OR] 2.87; 95% confidence interval [CI] 1.13-7.22; P = 0.024) and/or refractoriness (OR 3.03; 95% CI 1.27-7.3; P = 0.01).ConclusionsA CTnI level of > 0.25 μg L−1 at presentation in patients with TTP appears to be an independent factor associated with a three-fold increase in the risk of death or refractoriness. Therefore, cTnI level should be considered as a prognostic indicator in patients diagnosed with TTP.
Journal of Thrombosis and Haemostasis 11/2014; 13(2). · 6.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Infectious diseases remain a major public health issue in both developing and developed countries. For instance, there is still a high rate of morbidity and mortality due to seasonal influenza outbreaks and severe bacterial sepsis, despite major advances in their prevention and treatment. It is now clear that severe influenza and bacterial infections promote susceptibility for superinfections worsening the prognosis. Various immune defects acquired during severe infection may result in complex immunosuppression and may affect both innate and adaptive components. Some animal models of these common clinical situations have demonstrated the increased susceptibility of infected hosts to secondary infectious insult and allowed assessing the regulatory mechanisms. Such pathophysiological advances may help create new immunomodulatory therapeutics for infected patients exposed to severe secondary sepsis.
[Show abstract][Hide abstract] ABSTRACT: Determinants of outcome and long-term survival are unknown in elderly patients successfully resuscitated after out-of-hospital cardiac arrest. Our aim was to identify factors associated with short- and long-term neurologic outcome in such patients.
Critical Care Medicine 07/2014; · 6.15 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little attention has been given to ARDS in cancer patients, despite their high risk for pulmonary complications. We sought to describe outcomes in cancer patients with ARDS meeting the Berlin definition.
Intensive Care Medicine 06/2014; 40(8). · 5.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: L’intoxication à l’éthylène glycol est rare, mais son diagnostic est fondamental afin de débuter les thérapeutiques spécifiques. Nous rapportons le cas d’un patient admis en réanimation pour coma avec acidose métabolique majeure, causé par une intoxication grave à l’éthylène glycol. La gazométrie artérielle initial, analysée à l’aide de l’appareil de biochimie délocalisée disponible dans le service de réanimation, révélait une hyperlactatémie majeure, plus tard infirmée par un autre dosage pratiqué dans le service de biochimie. Une interférence entre les métabolites de l’éthylène glycol et la technique de dosage de certains appareils de biochimie délocalisée était à l’origine de cette fausse hyperlactatémie. L’hyperlactatémie artéfactuelle reflétait le taux d’éthylène glycol, suggérant que cette interférence pourrait être utilisée à des fins de suivi de l’évolution sous traitement des concentrations de l’alcool toxique, sans recours aux dosages coûteux et peu disponibles.
Annales francaises d'anesthesie et de reanimation 04/2014; · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The influence of blood glucose (BG) level during the post-resuscitation period after out-of-hospital cardiac arrest (OHCA) is still debated. To evaluate the relationship between blood glucose level and outcome, we included the median glycemia and its maximal amplitude over the first 48 h following ICU admission in an analysis of outcome predictors.
We conducted a database study in a cardiac arrest center in Paris, France. Between 2006 and 2010, we included 381 patients who were all resuscitated from an OHCA. A moderate glycemic control was applied in all patients. The median glycemia and the largest change over the first 48 h were included in a multivariate analysis that was performed to determine parameters associated with a favorable outcome.
Of the 381 patients, 136 (36 %) had a favorable outcome (CPC 1-2). Median BG level was 7.6 mmol/L (6.3-9.8) in patients with a favorable outcome compared to 9.0 mmol/L (IQR 7.1-10.6) for patients with an unfavorable outcome (p < 0.01). Median BG level variation was 7.1 (4.2-11) and 9.6 (5.9-13.6) mmol/L in patients with and without a favorable outcome, respectively (p < 0.01). In multivariate analysis, an increased median BG level over the first 48 h was found to be an independent predictor of poor issue [OR = 0.43; 95 % CI (0.24-0.78), p = 0.006]. Finally a progressive increase in median BG level was associated with a progressive increase in the proportion of patients with a poor outcome.
We observed a relationship between high blood glucose level and outcome after cardiac arrest. These results suggest the need to test a strategy combining both control of glycemia and minimization of glycemic variations for its ability to improve post-resuscitation care.
European Journal of Intensive Care Medicine 03/2014; · 5.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Infectious events have been reported as major environmental triggers of thrombotic thrombocytopenic purpura (TTP). We detail here the potential association between infections and TTP.
[Show abstract][Hide abstract] ABSTRACT: Les maladies infectieuses demeurent un problème majeur de santé publique, y compris dans les pays développés. Par exemple, les épidémies grippales et les infections bactériennes demeurent grevées d’une morbi-mortalité importante malgré les avancées réalisées dans la prévention et le traitement de ces maladies. Il est maintenant clairement établi que les infections grippales et bactériennes graves induisent une susceptibilité accrue à des infections secondaires qui grèvent significativement le pronostic. En effet, au cours des états infectieux graves, diverses anomalies immunologiques acquises peuvent aboutir à une immunodépression complexe qui affecte à la fois les composants de l’immunité innée et de l’immunité adaptive. Des modèles animaux modélisant ces situations cliniques communes ont permis de mettre en évidence la susceptibilité accrue de l’animal infecté à une agression infectieuse secondaire et d’évaluer les mécanismes qui régulent ces phénomènes. Ces avancées physiopathologiques permettent maintenant d’envisager des perspectives thérapeutiques immunomodulatrices chez les patients septiques exposés à des complications infectieuses secondaires.
[Show abstract][Hide abstract] ABSTRACT: In between innate and adaptive immunity, the recently identified innate-like mucosal-associated invariant T (MAIT) lymphocytes display specific reactivity to non-streptococcal bacteria. Whether they are involved in bacterial sepsis has not been investigated. We aimed to assess the number and the time course of circulating innate-like T lymphocytes (MAIT, NKT and γδ T cells) in critically ill septic and non-septic patients and to establish correlations with the further development of intensive care unit (ICU)-acquired infections.
We prospectively enrolled consecutive patients with severe sepsis and septic shock. Controls were critically ill patients with non-septic shock and age-matched healthy subjects. Circulating innate-like lymphocytes were enumerated using a flow cytometry assay at day 1, 4 and 7.
One hundred and fifty six patients (113 severe bacterial infections, 36 non-infected patients and 7 patients with severe viral infections) and 26 healthy subjects were enrolled into the study. Patients with severe bacterial infections displayed an early decrease in MAIT cell count [median 1.3/mm(3); interquartile range (0.4-3.2)] as compared to control healthy subjects [31.1/mm(3) (12.1-45.2)], but also to non-infected critically ill patients [4.3/mm(3) (1.4-13.2)] (P < 0.0001 for all comparisons). In contrast NKT and γδ T cell counts did not differ between patients groups. The multivariate analysis identified non-streptococcal bacterial infection as an independent determinant of decrease in MAIT cell count. Furthermore, the incidence of ICU-acquired infections was higher in patients with persistent MAIT cell depletion.
This large human study provides valuable information about MAIT cells in severe bacterial infections. The persistent depletion of MAIT cells is associated with the further development of ICU-acquired infections.
European Journal of Intensive Care Medicine 12/2013; 40(2). · 5.17 Impact Factor