The latest medical research on Intensive Care Medicine

Metabolic acidosis is a disorder frequently encountered in emergency medicine and intensive care medicine. As literature has been enriched with new...

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Guidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type.

Multicentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time.

Of 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups.

Rates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes.

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Recent European/American guidelines recommend noninvasive ventilation (NIV) as a first-line therapy to manage acute hypoxemic respiratory failure in immunocompromised patients. By contrast, NIV may have deleterious effects in nonimmunocompromised patients and experts have been unable to offer a recommendation. Immunocompromised patients have particularly high mortality rates when they require intubation. However, it is not clear whether immunosuppression status is a risk factor for NIV failure. We assessed the impact of immunosuppression status on NIV failure in a post hoc analysis pooling two studies including patients with de novo acute hypoxemic respiratory failure treated with NIV. Patients with hypercapnia, acute exacerbation of chronic lung disease, cardiogenic pulmonary edema, or with do-not-intubate order were excluded.

Among the 208 patients included in the analysis, 71 (34%) were immunocompromised. They had higher severity scores upon ICU admission, higher pressure-support levels, and minute ventilation under NIV, and were more likely to have bilateral lung infiltrates than nonimmunocompromised patients. Intubation and in-ICU mortality rates were higher in immunocompromised than in nonimmunocompromised patients: 61% vs. 43% (p = 0.02) and 38% vs. 15% (p < 0.001), respectively. After adjustment or using a propensity score-matched analysis, immunosuppression was not associated with intubation, whereas it remained independently associated with ICU mortality with an adjusted odds ratio of 2.64 (95% CI 1.24-5.67, p = 0.01).

Immunosuppression status may directly influence mortality but does not seem to be associated with an increased risk of intubation in patients with de novo acute hypoxemic respiratory failure treated with NIV. Studies in this specific population are needed.

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The electrical activity of the crural diaphragm (Eadi), a surrogate of respiratory drive, can now be measured at the bedside in mechanically ventilated patients with a specific catheter. The expected range of Eadi values under stressed or assisted spontaneous breathing is unknown. This study explored Eadi values in healthy subjects during unstressed (baseline), stressed (with a resistance) and assisted spontaneous breathing. The relation between Eadi and inspiratory effort was analyzed.

Thirteen healthy male volunteers were included in this randomized crossover study. Eadi and esophageal pressure (Peso) were recorded during unstressed and stressed spontaneous breathing and under assisted ventilation delivered in pressure support (PS) at low and high assist levels and in neurally adjusted ventilatory assist (NAVA). Overall eight different situations were assessed in each participant (randomized order). Peak, mean and integral of Eadi, breathing pattern, esophageal pressure-time product (PTPeso) and work of breathing (WOB) were calculated offline.

Median [interquartile range] peak Eadi at baseline was 17 [13-22] μV and was above 10 μV in 92% of the cases. Eadimax defined as Eadi measured at maximal inspiratory capacity reached 90 [63 to 99] μV. Median peak Eadi/Eadimax ratio was 16.8 [15.6-27.9]%. Compared to baseline, respiratory rate and minute ventilation were decreased during stressed non-assisted breathing, whereas peak Eadi and PTPeso were increased. During unstressed assisted breathing, peak Eadi decreased during high-level PS compared to unstressed non-assisted breathing and to NAVA (p = 0.047). During stressed breathing, peak Eadi was lower during all assisted ventilation modalities compared to stressed non-assisted breathing. During assisted ventilation, across the different conditions, peak Eadi changed significantly, whereas PTPeso and WOB/min were not significantly modified. Finally, Eadi signal was still present even when Peso signal was suppressed due to high assist levels.

Eadi analysis provides complementary information compared to respiratory pattern and to Peso monitoring, particularly in the presence of high assist levels. Trial registration The study was registered as NCT01818219 in clinicaltrial.gov. Registered 28 February 2013.

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This study aims to assess the changes in lung aeration and ventilation during the first spontaneous breathing trial (SBT) and after extubation in a population of patients at risk of extubation failure.

We included 78 invasively ventilated patients eligible for their first SBT, conducted with low positive end-expiratory pressure (2 cm H2O) for 30 min. We acquired three 5-min electrical impedance tomography (EIT) records at baseline, soon after the beginning (SBT_0) and at the end (SBT_30) of SBT. In the case of SBT failure, ventilation was reinstituted; otherwise, the patient was extubated and two additional records were acquired soon after extubation (SB_0) and 30 min later (SB_30) during spontaneous breathing. Extubation failure was defined by the onset of post-extubation respiratory failure within 48 h after extubation. We computed the changes from baseline of end-expiratory lung impedance (∆EELI), tidal volume (∆Vt%), and the inhomogeneity index. Arterial blood was sampled for gas analysis. Data were compared between sub-groups stratified for SBT and extubation success/failure.

Compared to SBT success (n = 61), SBT failure (n = 17) showed a greater reduction in ∆EELI at SBT_0 (p < 0.001) and SBT_30 (p = 0.001) and a higher inhomogeneity index at baseline (p = 0.002), SBT_0 (p = 0.003) and SBT_30 (p = 0.005). RR/Vt was not different between groups at baseline but was significantly greater at SBT_0 and SBT_30 in SBT failures, compared to SBT successes (p < 0.001 for both). No differences in ∆Vt% and arterial blood gases were observed between SBT success and failure. The ∆Vt%, ∆EELI, inhomogeneity index and arterial blood gases were not different between patients with extubation success (n = 39) and failure (n = 22) (p > 0.05 for all comparisons).

Compared to SBT success, SBT failure was characterized by more lung de-recruitment and inhomogeneity. Whether EIT may be useful to monitor SBT remains to be determined. No significant changes in lung ventilation, aeration or homogeneity related to extubation outcome occurred up to 30 min after extubation. Trial registration Retrospectively registered on clinicaltrials.gov (Identifier: NCT03894332; release date 27th March 2019).

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The evidence of a clinical benefit of P2Y12 inhibitor pre-treatment in primary percutaneous coronary intervention (PCI) and the relation between the level of platelet inhibition and myocardial reperfusion with newer potent P2Y12 inhibitors remain unclear. We aimed to assess the relationship between platelet reactivity at the time of primary PCI after pre-treatment with aspirin and ticagrelor and the post-PCI myocardial blush grade (MBG).

We prospectively included 61 patients. Platelet reaction units for ticagrelor (PRU) and aspirin reaction units (ARU) were measured using the point-of-care test VerifyNow before PCI. The high on-ticagrelor (PRU >208) and on-aspirin (ARU ⩾ 550) platelet reactivity (HPR and HaPR) were assessed. Patients were divided into two groups according to MBG 3 or <3.

MBG 3 was identified in 28 (46%) patients. Mean PRU was lower in such patients as compared with those with MBG <3 (155.82 ± 90.91 vs. 227.42 ± 65.18; p=0.001) while mean ARU was similar between groups. HPR and HaPR were observed in 30 (49.2%) and 11 patients (18%), respectively. HPR but not HaPR was more frequent in the group with impaired MBG (66.7 vs. 28.6%; p=0.003 and 21.2 vs. 14.3%; p=0.48 respectively).

Our study shows that higher PRU and the subsequent HPR at the time of primary PCI, after pretreatment with ticagrelor, are the only correlates of post PCI MBG. These findings support the earliest possible loading with ticagrelor prior to primary PCI.

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The turbulence of blood flow caused by stenosis has an impact on the surrounding coronary artery tissue and creates an audio-frequency vibration to the adjacent myocardial wall. We investigated the diagnostic feasibility of a novel diagnostic method using wide range gate (WRG) ultrasound data acquisition for diagnosing coronary artery disease (CAD). WRG data acquisition detects high-frequency vibrations from coronary artery stenosis, using pulse-wave Doppler ultrasound.

We used a Verasonics ultrasound data acquisition system to implement the WRG data acquisition. Investigators performed clinical trials for 80 subjects, with suspected CAD. All enrolled patients participated in WRG data acquisition before coronary angiography (CAG).

As compared with the results of CAG, the sensitivity and specificity of the WRG data analysis were 80% and 84%, respectively. The WRG data analysis showed that the sensitivity and specificity were 81% and 79% in the left anterior descending artery, respectively, 75% and 89% in the left circumflex artery, respectively, and 85% and 82% in the right coronary artery, respectively. In a multivariate analysis, a positive vibrometry result was an independent predictive factor for CAD.

We proposed a new diagnostic method for detecting CAD using ultrasound. The new data acquisition method showed good potential as an initial diagnostic tool for CAD.

Chloroma or myeloid sarcoma is rare extramedullary tumor composed of immature myeloid cells that may occur in association with or during or even be...

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Our study investigated left ventricular dyssynchrony (LVD) in coronary artery disease (CAD) patients without regional wall-motion abnormality (RWMA) by three-dimensional echocardiography (3-DE) and explored the relationship between LVD and severity of CAD as assessed by the Gensini score (GS).

Sixty-one patients with a confirmed diagnosis of CAD by coronary angiography (CAG) were enrolled. We quantified LVD parameters, including the left ventricular segments (16, 12, and 6) standard deviation of the time to minimum systolic volume (TmsvSD-16, TmsvSD-12, and TmsvSD-6) and the systolic dyssynchrony index in regions 16, 12, and 6 (16R-SDI, 12R-SDI, 6R-SDI) using 3-DE. The severity of coronary atherosclerotic lesions was evaluated by the GS system on the basis of CAG findings. We further divided all patients into three groups according to the tertiles of GS: low-GS ≤20, mid-GS >20 and ≤48, and high-GS >48. The differences of LVD values among the three groups were compared, and the associations between LVD parameters and GS were analyzed.

Coronary artery disease patients demonstrated increased LVD parameters compared with healthy controls. TmsvSD12, 16R-SDI, and 6R-SDI were prolonged in the high-GS group compared with the low- and mid-GS groups. 16R-SDI was positively correlated with the GS, and multivariate regression analysis showed that 16R-SDI was an independent predictor of the GS. 16R-SDI above 10.7% had a sensitivity of 84.21% and a specificity of 92.86% for identifying high-GS.

Three-dimensional echocardiography is a noninvasive technique to detect LVD in non-RWMA CAD patients, and the parameter 16R-SDI was significantly correlated with CAD severity.

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Microbiological confirmation of pulmonary tuberculosis in children is desirable.

To investigate the diagnostic accuracy and incremental yield of Xpert-Ultra, a new rapid test, on repeated induced sputum, nasopharyngeal aspirates and combinations of specimens.

Induced sputum and nasopharyngeal aspirates were obtained. Nasopharyngeal aspirates were frozen; induced sputum underwent liquid culture, an aliquot was frozen. Ultra was performed on thawed nasopharyngeal aspirates and induced sputum specimens individually. Children were categorised as confirmed, unconfirmed or unlikely tuberculosis according to NIH consensus case definitions. The diagnostic accuracy of Ultra was compared with liquid culture on induced sputum.

195 children [median age 23·3 months, 32(16·4%) HIV-infected] had one induced sputum and nasopharyngeal aspirate; 130 had two nasopharyngeal aspirates. There were 40(20·5%) culture confirmed cases. Ultra was positive on nasopharyngeal aspirates in 26(13·3%) and on induced sputum in 31(15·9%). Sensitivity and specificity of Ultra on one nasopharyngeal-aspirate were 46% and 98% respectively, similar by HIV status. Sensitivity and specificity of Ultra on one induced sputum were 74·3% and 96·9% respectively. Combining one nasopharyngeal aspirate and one induced sputum increased sensitivity to 80%. Sensitivity using Ultra on two nasopharyngeal aspirates was 54.2%, increasing to 87.5% with an induced sputum Ultra.

Induced sputum provides a better specimen than repeated nasopharyngeal aspirate for rapid diagnosis using Ultra. However, Ultra testing of combinations of specimens provides a novel strategy that can be adapted to identify most children with confirmed pulmonary tuberculosis.

The term bronchiectasis describes a complex and heterogeneous clinical syndrome which can be characterized by chronic respiratory symptoms and perm...

Acute kidney injury (AKI) is a complex syndrome defined by a decrease in renal function. The incidence of AKI has raised in the past decades, and i...

The latest medical research on Intensive Care Medicine

Diagnosis and management of metabolic acidosis: guidelines from a French expert panel.

Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study.

Is immunosuppression status a risk factor for noninvasive ventilation failure in patients with acute hypoxemic respiratory failure? A post hoc matched analysis.

Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiological study.

Electrical impedance tomography during spontaneous breathing trials and after extubation in critically ill patients at high risk for extubation failure: a multicenter observational study.

Residual platelet reactivity after pre-treatment with ticagrelor prior to primary percutaneous coronary intervention is associated with suboptimal myocardial reperfusion.

A wide range gate data acquisition for diagnosing coronary artery disease.

Cardiac chloroma or cardiac myeloid sarcoma: Case Report.

Left ventricular dyssynchrony in coronary artery disease patients without regional wall-motion abnormality: Correlation with Gensini score.

Tuberculosis Diagnosis in Children Using Xpert Ultra on Different Respiratory Specimens.

Clinical Fingerprinting: A Way to Address the Complexity and Heterogeneity of Bronchiectasis in Practice.

Complete blood count in acute kidney injury prediction: a narrative review.

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