Modifiable and nonmodifiable risk factors for postoperative delirium after cardiac surgery with cardiopulmonary bypass.

Postoperative delirium after cardiac surgery is associated with increased morbidity and mortality as well as prolonged stay in both the intensive care unit and the hospital. The authors sought to identify modifiable risk factors associated with the development of postoperative delirium in elderly patients after elective cardiac surgery in order to be able to design follow-up studies aimed at the prevention of delirium by optimizing perioperative management. A post hoc analysis of data from patients enrolled in a randomized controlled trial was performed. A single university hospital. One hundred thirteen patients aged 65 or older undergoing elective cardiac surgery with cardiopulmonary bypass. None. MEASUREMENTS AND MAINS RESULTS: Screening for delirium was performed using the Confusion Assessment Method (CAM) on the first 6 postoperative days. A multivariable logistic regression model was developed to identify significant risk factors and to control for confounders. Delirium developed in 35 of 113 patients (30%). The multivariable model showed the maximum value of C-reactive protein measured postoperatively, the dose of fentanyl per kilogram of body weight administered intraoperatively, and the duration of mechanical ventilation to be independently associated with delirium. In this post hoc analysis, larger doses of fentanyl administered intraoperatively and longer duration of mechanical ventilation were associated with postoperative delirium in the elderly after cardiac surgery. Prospective randomized trials should be performed to test the hypotheses that a reduced dose of fentanyl administered intraoperatively, the use of a different opioid, or weaning protocols aimed at early extubation prevent delirium in these patients.

Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology.

BACKGROUND: Open lung biopsy (OLB) is helpful in the management of patients with acute respiratory distress syndrome (ARDS) of unknown etiology. We determine the impact of surgical lung biopsies performed at the bedside on the management of patients with ARDS. METHODS: We reviewed all consecutive cases of patients with ARDS who underwent a surgical OLB at the bedside in a medical intensive care unit between 1993 and 2005. RESULTS: Biopsies were performed in 19 patients mechanically ventilated for ARDS of unknown etiology despite extensive diagnostic process and empirical therapeutic trials. Among them, 17 (89%) were immunocompromised and 10 patients experienced hematological malignancies. Surgical biopsies were obtained after a median (25%-75%) mechanical ventilation of 5 (2-11) days; mean (+/-SD) Pao(2)/Fio(2) ratio was 119.3 (+/-34.2) mm Hg. Histologic diagnoses were obtained in all cases and were specific in 13 patients (68%), including 9 (47%) not previously suspected. Immediate complications (26%) were local (pneumothorax, minimal bleeding) without general or respiratory consequences. The biopsy resulted in major changes in management in 17 patients (89%). It contributed to a decision to limit care in 12 of 17 patients who died. CONCLUSION: Our data confirm that surgical OLB may have an important impact on the management of patients with ARDS of unknown etiology after extensive diagnostic process. The procedure can be performed at the bedside, is safe, and has a high diagnostic yield leading to major changes in management, including withdrawal of vital support, in the majority of patients.

Barbiturate infusion for intractable intracranial hypertension and its effect on brain oxygenation.

OBJECTIVE: Barbiturate-induced coma can be used in patients to treat intractable intracranial hypertension when other therapies, such as osmotic therapy and sedation, have failed. Despite control of intracranial pressure, cerebral infarction may still occur in some patients, and the effect of barbiturates on outcome remains uncertain. In this study, we examined the relationship between barbiturate infusion and brain tissue oxygen (PbtO2). METHODS: Ten volume-resuscitated brain-injured patients who were treated with pentobarbital infusion for intracranial hypertension and underwent PbtO2 monitoring were studied in a neurosurgical intensive care unit at a university-based Level I trauma center. PbtO2, intracranial pressure (ICP), mean arterial pressure, cerebral perfusion pressure (CPP), and brain temperature were continuously monitored and compared in settings in which barbiturates were or were not administered. RESULTS: Data were available from 1595 hours of PbtO2 monitoring. When pentobarbital administration began, the mean ICP, CPP, and PbtO2 were 18 +/- 10, 72 +/- 18, and 28 +/- 12 mm Hg, respectively. During the 3 hours before barbiturate infusion, the maximum ICP was 24 +/- 13 mm Hg and the minimum CPP was 65 +/- 20 mm Hg. In the majority of patients (70%), we observed an increase in PbtO2 associated with pentobarbital infusion. Within this group, logistic regression analysis demonstrated that a higher likelihood of compromised brain oxygen (PbtO2 < 20 mm Hg) was associated with a decrease in pentobarbital dose after controlling for ICP and other physiological parameters (P < 0.001). In the remaining 3 patients, pentobarbital was associated with lower PbtO2 levels. These patients had higher ICP, lower CPP, and later initiation of barbiturates compared with patients whose PbtO2 increased. CONCLUSION: Our preliminary findings suggest that pentobarbital administered for intractable intracranial hypertension is associated with a significant and independent increase in PbtO2 in the majority of patients. However, in some patients with more compromised brain physiology, pentobarbital may have a negative effect on PbtO2, particularly if administered late. Larger studies are needed to examine the relationship between barbiturates and cerebral oxygenation in brain-injured patients with refractory intracranial hypertension and to determine whether PbtO2 responses can help guide therapy.

Patients' preferences on information and involvement in decision making for gastrointestinal surgery.

BACKGROUND: The relationship between physicians and patients has undergone important changes, and the current emancipation of patients has led to a real partnership in medical decision making. The present study aimed to assess patients' preferences on different aspects of decision making during treatment and potential complications, as well as the amount and type of preoperative information wanted before visceral surgery. METHODS: This was a prospective non-randomized study based on a questionnaire given to 253 consecutive patients scheduled for elective gastrointestinal surgery. RESULTS: In considering surgical complications or treatment in the intensive care unit, 64 % of patients wished to take an active role in any medical decisions. The respective figures for cardiac resuscitation and treatment limitations were 89 and 60 %. As for information, 73, 77, and 47 % of patients wish detailed information, information on a potential ICU hospitalization, and knowledge of cardiac resuscitation, respectively. Elderly and low-educated patients were significantly less interested in shared medical decision making (p = 0.003 and 0.015), and in receiving information (p = 0.03 and 0.05). Similarly, involvement of the family in decision making was significantly less important to elderly and male patients (p = 0.05 and 0.03, respectively). Neither the type of operation (minor or major) nor the severity of disease (malignancies versus non-malignancies) was a significant factor for shared decision making, information, or family involvement. CONCLUSIONS: The vast majority of surgical patients clearly want to get adequate preoperative information about their disease and the planned treatment. They also consider it crucial to be involved in any kind of decision making for treatment and complications. For most patients, the family role is limited to supporting the treating physicians if the patient is unable to participate in decision making.

Transapical aortic valve replacement in extreme-risk patients: outcome, risk factors and mid-term results.

OBJECTIVES: Transcatheter aortic valve replacement (TAVR) provides good results in selected high-risk patients. However, it is unclear whether this procedure carries advantages in extreme-risk profile patients with logistic EuroSCORE above 35%. METHODS: From January 2009 to July 2011, of a total number of 92 transcatheter aortic valve procedures performed, 40 'extreme-risk' patients underwent transapical TAVR (TA-TAVR) (EuroSCORE above 35%). Variables were analysed as risk factors for hospital and mid-term mortality, and a 2-year follow-up (FU) was obtained. RESULTS: The mean age was: 81 ± 10 years. Twelve patients (30%) had chronic pulmonary disease, 32 (80%) severe peripheral vascular disease, 14 (35%) previous cardiac surgery, 19 (48%) chronic renal failure (2 in dialysis), 7 (17%) previous stroke (1 with disabilities), 3 (7%) a porcelain aorta and 12 (30%) were urgent cases. Mean left ventricle ejection fraction (LVEF) was 49 ± 13%, and mean logistic EuroSCORE was 48 ± 11%. Forty stent-valves were successfully implanted with six Grade-1 and one Grade-2 paravalvular leakages (success rate: 100%). Hospital mortality was 20% (8 patients). Causes of death following the valve academic research consortium (VARC) definitions were: life-threatening haemorrhage (1), myocardial infarction (1), sudden death (1), multiorgan failure (2), stroke (1) and severe respiratory dysfunction (2). Major complications (VARC definitions) were: myocardial infarction for left coronary ostium occlusion (1), life-threatening bleeding (2), stroke (2) and acute kidney injury with dialysis (2). Predictors for hospital mortality were: conversion to sternotomy, life-threatening haemorrhage, postoperative dialysis and long intensive care unit (ICU) stay. Variables associated with hospital mortality were: conversion to sternotomy (P = 0.03), life-threatening bleeding (P = 0.02), acute kidney injury with dialysis (P = 0.03) and prolonged ICU stay (P = 0.02). Mean FU time was 24 months: actuarial survival estimates for all-cause mortality at 6 months, 1 year, 18 months and 2 years were 68, 57, 54 and 54%, respectively. Patients still alive at FU were in good clinical condition, New York Heart Association (NYHA) class 1-2 and were never rehospitalized for cardiac decompensation. CONCLUSIONS: TA-TAVR in extreme-risk patients carries a moderate risk of hospital mortality. Severe comorbidities and presence of residual paravalvular leakages affect the mid-term survival, whereas surviving patients have an acceptable quality of life without rehospitalizations for cardiac decompensation.

Perforation cardiaque d'un ulcère gastrique: une cause inhabituelle de décès, après résection oesogastrique pour carcinome épidermoïde de l'oesophage [Cardiac perforation by a gastric ulcer: an unusual cause of death, after an esophageal and gastric resection of an epidermoid esophageal carcinoma]

We report here the case of a 55 year old female that underwent surgery for a well differentiated squamous cell carcinoma of the esophagus (middle third). Four months after surgery, she complains of neck pain, for which she is prescribed non steroidal antiinflammatory drugs (NSAID). A CT-scan and a Barium swallow are then normal. After three weeks of treatment, the patient is admitted on emergency to the Intensive Care Unit for a resuscitation hematemesis and atrial fibrillation with a fast ventricular response. The symptoms are stabilized after the transfusion of a few packed red blood cells. A few hours later, however, a massive hematemesis recurs and the patient dies despite intense resuscitation measures. Autopsy reveals three gastric ulcers, one of which had perforated through the cardiac left ventricular wall

Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients.

INTRODUCTION: Oxidative stress is involved in the development of secondary tissue damage and organ failure. Micronutrients contributing to the antioxidant (AOX) defense exhibit low plasma levels during critical illness. The aim of this study was to investigate the impact of early AOX micronutrients on clinical outcome in intensive care unit (ICU) patients with conditions characterized by oxidative stress. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled, single-center trial in patients admitted to a university hospital ICU with organ failure after complicated cardiac surgery, major trauma, or subarachnoid hemorrhage. Stratification by diagnosis was performed before randomization. The intervention was intravenous supplements for 5 days (selenium 270 microg, zinc 30 mg, vitamin C 1.1 g, and vitamin B1 100 mg) with a double-loading dose on days 1 and 2 or placebo. RESULTS: Two hundred patients were included (102 AOX and 98 placebo). While age and gender did not differ, brain injury was more severe in the AOX trauma group (P = 0.019). Organ function endpoints did not differ: incidence of acute kidney failure and sequential organ failure assessment score decrease were similar (-3.2 +/- 3.2 versus -4.2 +/- 2.3 over the course of 5 days). Plasma concentrations of selenium, zinc, and glutathione peroxidase, low on admission, increased significantly to within normal values in the AOX group. C-reactive protein decreased faster in the AOX group (P = 0.039). Infectious complications did not differ. Length of hospital stay did not differ (16.5 versus 20 days), being shorter only in surviving AOX trauma patients (-10 days; P = 0.045). CONCLUSION: The AOX intervention did not reduce early organ dysfunction but significantly reduced the inflammatory response in cardiac surgery and trauma patients, which may prove beneficial in conditions with an intense inflammation. TRIALS REGISTRATION: Clinical Trials.gov RCT Register: NCT00515736.

Influence d'une hospitalisation prénatale sur les facteurs de stress

But. - Investiguer l'influence d'une hospitalisation prénatale précédant une naissance préma¬turée sur les facteurs de stress parentaux et la relation parent-enfant lors de l'hospitalisation en néonatologie ainsi que sur les symptômes de stress post-traumatique parentaux. Population et méthodes. - Population : 51 enfants prématurés et 25 enfants nés à terme (groupe témoin). Quatre groupes : groupe témoin, prématurés sans hospitalisation prénatale, prématu¬rés avec hospitalisation courte (< 8 jours) et prématurés avec hospitalisation longue (> 8 jours). Instruments: le Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU, Miles et al., 1993 [14]) et le Perinatal PTSD Questionnaire (PPQ, Quinnell et Hynan, 1999 [16]). Résultats. -En cas d'hospitalisation prénatale, les parents se disent plus stressés par l'environnement du bébé en néonatologie. Les mères avec une hospitalisation prénatale courte (< 8 jours) se différencient significativement du groupe témoin par plus de symptômes de stress post-traumatique. Les parents présentant plus de symptômes post-traumatiques décrivent la relation avec leur bébé en néonatologie comme significativement plus difficile. Conclusion. - Cette étude indique l'attention à apporter aux patientes hospitalisées brièvement en prénatal (< 8 jours). Il s'agit d'un groupe plus à risque de présenter des symptômes de stress post-traumatique qui peuvent engendrer des troubles dans la relation à l'enfant.

Pancreatic stone protein as a postmortem biochemical marker for the diagnosis of sepsis.

Pancreatic stone protein/regenerating protein has recently emerged as an interesting diagnostic and prognostic marker of inflammation and sepsis in the clinical field. Increased blood concentrations have been described in patients with sepsis. Moreover, a high accuracy in predicting fatal outcomes in septic patients admitted to intensive care units has been reported. In this study, we investigated pancreatic stone protein/regenerating protein in postmortem serum in a series of sepsis-related fatalities, local infections and non-infectious cases that underwent medico-legal investigations. Procalcitonin, C-reactive protein, interleukin 6, soluble triggering receptor expressed on myeloid cells-1 and pancreatic stone protein/regenerating protein were measured in the postmortem serum collected during autopsy in a group of sepsis-related deaths, local infections and non-septic intensive care unit patients. Statistically significant differences in pancreatic stone protein/regenerating protein concentrations were observed between sepsis and control patients. A significant positive correlation was found between procalcitonin and pancreatic stone protein/regenerating protein values in septic cases. Pancreatic stone protein/regenerating protein is measurable in postmortem serum from femoral blood collected during autopsy. Additionally, as in the clinical field, pancreatic stone protein/regenerating protein can be used as a postmortem biochemical marker for the diagnosis of sepsis.

Oral pregabalin as an add-on treatment for status epilepticus.

Oral antiepileptic drugs (AEDs) represent possible add-on options in refractory status epilepticus (SE). In this setting, pregabalin (PGB) has not been reported before. Over the last 42 months, we identified 11 SE episodes (10 patients) treated with PGB in our hospital. Its use was prompted by the favorable pharmacokinetic profile, devoid of drug-drug interactions. The patients mostly had refractory, partial SE. Only two patients were managed in the intensive care unit (ICU). We found a definite electroclinical response in 5 of 11, already evident 24 h after PGB introduction, and a possible response (concomitantly with other AEDs) in 3 of 11 of the episodes; 3/11 did not respond. The treatment was well tolerated. Partial SE appeared to better respond than generalized convulsive SE. PGB appears to be an interesting option as add-on treatment in refractory partial SE.

L'hépatectomie réglée. A propos de 18 cas opérés dans un hôpital périphérique [Standardized hepatectomy. 18 cases operated in a peripheral hospital]

Hepatectomy has long been a formidable surgical procedure because the risk of hemorrhage it can involve. With a better understanding of hepatic anatomy, left hepatectomy, right hepatectomy and segmental hepatic resections have been standardized. Between January 1989 and December 1992, 18 hepatectomies were performed on 16 patients in the Department of Surgery, General Hospital, La Chaux-de-Fonds, Switzerland. The mean age of the patients was 65. The surgical indications were: hepatic metastases 11 (61%); gallbladder or biliary duct neoplasm 4 (22%); hydatic cyst 3 (17%). 11 segmental resection, 3 left hepatectomies, 2 right hepatectomies, 2 pericystectomies were performed. Blood loss during these operations averaged 2800 ml. Surgical complications appeared in 6 cases (hemorrhage 1, postoperative effusion 4, sepsis 1). One patient died within 30 days (mortality 5%). Hepatectomy is nowadays a safe procedure. It can be performed in a general hospital with a trained surgical team and an efficient intensive care unit

Concomitant administration of intravenous drugs in the ICU: evaluation of physico-chemical compatibilities

Background and objective: Patients in the ICU often get many intravenous (iv) drugs at the same time. Even with three-lumen central venous catheters, the administration of more than one drug in the same iv line (IVL) is frequently necessary. The objective of this study was to observe how nurses managed to administer these many medications and to evaluate the proportion of two-drugs associations (TDA) that are compatible or not, based on known compatibility data. Design: Observational prospective study over 4 consecutive months. All patients receiving simultaneously more than one drugs in the same IVL (Y-site injection or mixed in the same container) were included. For each patient, all iv drugs were recorded, as well as concentration, infusion solution, location on the IVL system, time, rate and duration of administration. For each association of two or more drugs, compatibility of each drug was checked with each other. Compatibilities between these pairs of drugs were assessed using published data (mainly Trissel LA. Handbook on Injectable Drugs and Trissel's Tables of Physical Compatibility) and visual tests performed in our quality control laboratory. Setting: 34 beds university hospital adult ICU. Main outcome measures: Percentage of compatibilities and incompatibilities between drugs administered in the same IVL. Results: We observed 1,913 associations of drugs administered together in the same IVL, 783 implying only two drugs. The average number of drugs per IVL was 3.1 ± 0.8 (range: 2-9). 83.2% of the drugs were given by continuous infusion, 14.3% by intermittent infusion and 2.5% in bolus. The associations observed allowed to form 8,421 pairs of drugs (71.7% drug-drug and 28.3% drug-solute). According to literature data, 80.2% of the association were considered as compatible and 4.4% incompatible. 15.4% were not interpretable because of different conditions between local practices and those described in the literature (drug concentration, solute, etc.) or because of a lack of data. After laboratory tests performed on the most used drugs (furosemide, KH2PO4, morphine HCl, etc.), the proportion of compatible TDA raised to 85.7%, the incompatible stayed at 4.6% and only 9.7% remain unknown or not interpretable. Conclusions: Nurses managed the administration of iv medications quite well, as only less than 5% of observed TDA were considered as incompatible. But the 10% of TDA with unavailable compatibility data should have been avoided too, since the consequences of their concomitant administration cannot be predictable. For practical reasons, drugs were analysed only by pairs, which constitutes the main limit of this work. The average number of drugs in the same association being three, laboratory tests are currently performed to evaluate some of the most observed three-drugs associations.

Outcome Prediction after Cardiac Arrest Treated with Hypothermia

Rationale: Clinical and electrophysiological prognostic markers of brain anoxia have been mostly evaluated in comatose survivors of out hospital cardiac arrest (OHCA) after standard resuscitation, but their predictive value in patients treated with mild induced hypothermia (IH) is unknown. The objective of this study was to identify a predictive score of independent clinical and electrophysiological variables in comatose OHCA survivors treated with IH, aiming at a maximal positive predictive value (PPV) and a high negative predictive value (NPV) for mortality. Methods: We prospectively studied consecutive adult comatose OHCA survivors from April 2006 to May 2009, treated with mild IH to 33-34_C for 24h at the intensive care unit of the Lausanne University Hospital, Switzerland. IH was applied using an external cooling method. As soon as subjects passively rewarmed (body temperature >35_C) they underwent EEG and SSEP recordings (off sedation), and were examined by experienced neurologists at least twice. Patients with status epilepticus were treated with AED for at least 24h. A multivariable logistic regression was performed to identify independent predictors of mortality at hospital discharge. These were used to formulate a predictive score. Results: 100 patients were studied; 61 died. Age, gender and OHCA etiology (cardiac vs. non-cardiac) did not differ among survivors and nonsurvivors. Cardiac arrest type (non-ventricular fibrillation vs. ventricular fibrillation), time to return of spontaneous circulation (ROSC) >25min, failure to recover all brainstem reflexes, extensor or no motor response to pain, myoclonus, presence of epileptiform discharges on EEG, EEG background unreactive to pain, and bilaterally absent N20 on SSEP, were all significantly associated with mortality. Absent N20 was the only variable showing no false positive results. Multivariable logistic regression identified four independent predictors (Table). These were used to construct the score, and its predictive values were calculated after a cut-off of 0-1 vs. 2-4 predictors. We found a PPV of 1.00 (95% CI: 0.93-1.00), a NPV of 0.81 (95% CI: 0.67-0.91) and an accuracy of 0.93 for mortality. Among 9 patients who were predicted to survive by the score but eventually died, only 1 had absent N20. Conclusions: Pending validation in a larger cohort, this simple score represents a promising tool to identify patients who will survive, and most subjects who will not, after OHCA and IH. Furthermore, while SSEP are 100% predictive of poor outcome but not available in most hospitals, this study identifies EEG background reactivity as an important predictor after OHCA. The score appears robust even without SSEP, suggesting that SSEP and other investigations (e.g., mismatch negativity, serum NSE) might be principally needed to enhance prognostication in the small subgroup of patients failing to improve despite a favorable score.

Le sevrage ultra-rapide sous anesthésie générale: l'expérience de l'Hôpital de St-Loup [Ultrafast opiate detoxification under general anesthesia: the St. Loup Hospital experience]

Rapid antagonist induction under anesthesia is a method that has been increasingly used to detoxify opiate addicts. These procedures are useful to reduce the duration and the discomfort of withdrawal. However, the high risk and the cost of these methods require randomized clinical trial to evaluate safety and clinical effectiveness. The University Substance Abuse Division of Lausanne and the Intensive Care Unit of the St-Loup Hospital work on a randomized clinical trial comparing anesthesia-assisted versus traditional clonidine detoxification combined with an additional psychosocial week. This paper describes the technique of anesthesia used in our study. Our clinical experience suggests that, integrating this technique in a multidisciplinary network, with a strong emphasis on post-anesthetic follow-up, is a viable and safe option in the treatment of opiate dependence.

Prospective determination of imipenem concentration of the plasma of critically-ill children

ABSTRACT Imipenem plasma-concentrations were measured in 19 critically-ill children (median 0.8 year, range 0.02-12.9 years). Wide inter-individual variations (2-4x at peak and >10x at through concentrations) resulted in unpredictable plasma-levels in several children. To avoid subtherapeutic drug levels we recommend at least 100 mg/kg/day of imipenem-cilastatin in critically-ill children requiring such therapy.