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A 69-year-old woman with arterial hypertension treated daily by hydrochlorothiazide and angiotensin receptor antagonist received a first dose of Oxford–AstraZeneca vaccine. Eleven days after the vaccination, the patient developed headache associated with behavioral symptoms. At day 13, her daughter found her unconscious. Physical examination revealed a coma Glasgow 4/15, right mydriasis, bilateral Babinski reflex without hemodynamic instability or respiratory failure. She was intubated and transferred in our intensive care unit.

This case report describes immune thrombocytopenic purpura in a 41-year-old man hospitalized in the intensive-care unit for COVID-19, 13 days after the onset of COVID-19 symptoms with respiratory failure at admission. Acute respiratory distress syndrome was treated with, among other drugs, low-molecular-weight heparin. On day 8, his platelet count began descending rapidly. On day 10, heparin treatment was replaced by danaparoid sodium, but by day 13, the continued low platelet count made a diagnosis of heparin-induced thrombocytopenia unlikely. Normocytic nonregenerative anemia gradually developed. On day 13, a bone marrow aspiration showed numerous megakaryocytes and a few signs of hemophagocytosis. Corticosteroids were introduced on day 14, and platelets began rising after 3 days and then fell again on day 19. Intravenous immunoglobulin (IV Ig) was then administered. Two days later, the platelet count returned to normal. The immune cause was confirmed by ruling out the differential diagnoses and the excellent and rapid response to intravenous immunoglobulins. Finally, the patient's respiratory state improved. He was discharged to a respiratory rehabilitation unit on day 38. Our case suggests that an immunological cause should be considered in patients with thrombocytopenia during COVID-19.

Background Corticosteroids are now recommended in guidelines for patients with acute respiratory distress syndrome (ARDS); however, optimal timing and dose remain uncertain. We assessed whether the association between corticosteroids and hospital mortality varies over time in the ICU. Methods We performed a retrospective observational study of ARDS patients identified in the MIMIC-IV database (2008–2019). To analyze the time-varying association between corticosteroids and hospital mortality, we constructed overlapping three-day windows from ARDS days 0 to 14. We compared windows with no corticosteroid exposure (0 mg) to windows meeting cumulative prednisolone-equivalent dose thresholds chosen to approximate regimens from landmark clinical trials (≥ 30, ≥ 150, ≥270, ≥ 390 mg PE over 3 days). We estimated overlap-weighted, doubly robust adjusted risk differences (OWRD) for hospital mortality using augmented inverse probability weighting (AIPW). Results Of 987 included patients, 354 (35.9%) received corticosteroids, with 262 (74.1%) and 128 (36.2%) of treated patients meeting the ≥ 150 mg and ≥ 390 mg thresholds in at least one window. Early, low cumulative dosing (≥ 30 mg/3d) was not associated with a detectable difference in hospital mortality (e.g., days 0–2: OWRD 0.03, 95% CI − 0.05 to 0.10). Conversely, higher cumulative doses received later in the ICU stay (≥ 150–390 mg/3d after day 8) were associated with higher observed mortality (e.g., days 8–10: OWRD 0.25, 95% CI 0.11–0.39). However, estimates in late, high-dose windows were less precise due to limited covariate overlap and smaller sample sizes. Conclusions In unselected ARDS, we found no evidence of benefit or harm from early lower-dose corticosteroids, but higher cumulative doses later in ICU stay were associated with higher mortality, possibly reflecting residual confounding and limited covariate overlap. These hypothesis generating findings support randomized studies testing corticosteroid timing and dose in ARDS.

Background High-flow nasal oxygen therapy (HFNC) may be an attractive first-line ventilatory support in COVID-19 patients. However, HNFC use for the management of COVID-19 patients and risk factors for HFNC failure remain to be determined. Methods In this retrospective study, we included all consecutive COVID-19 patients admitted to our intensive care unit (ICU) in the first (Mars-May 2020) and second (August 2020- February 202) French pandemic waves. Patients with limitations for intubation were excluded. HFNC failure was defined as the need for intubation after ICU admission. The impact of HFNC use was analyzed in the whole cohort and after constructing a propensity score. Risk factors for HNFC failure were identified through a landmark time-dependent cause-specific Cox model. The ability of the 6-h ROX index to detect HFNC failure was assessed by generating receiver operating characteristic (ROC) curve. Results 200 patients were included: HFNC was used in 114(57%) patients, non-invasive ventilation in 25(12%) patients and 145(72%) patients were intubated with a median delay of 0 (0–2) days after ICU admission. Overall, 78(68%) patients had HFNC failure. Patients with HFNC failure had a higher ICU mortality rate (34 vs. 11%, p = 0.02) than those without. At landmark time of 48 and 72 h, SAPS-2 score, extent of CT-Scan abnormalities > 75% and HFNC duration (cause specific hazard ratio (CSH) = 0.11, 95% CI (0.04–0.28), per + 1 day, p < 0.001 at 48 h and CSH = 0.06, 95% CI (0.02–0.23), per + 1 day, p < 0.001 at 72 h) were associated with HFNC failure. The 6-h ROX index was lower in patients with HFNC failure but could not reliably predicted HFNC failure with an area under ROC curve of 0.65 (95% CI(0.52–0.78), p = 0.02). In the matched cohort, HFNC use was associated with a lower risk of intubation (CSH = 0.32, 95% CI (0.19–0.57), p < 0.001). Conclusions In critically-ill COVID-19 patients, while HFNC use as first-line ventilatory support was associated with a lower risk of intubation, more than half of patients had HFNC failure. Risk factors for HFNC failure were SAPS-2 score and extent of CT-Scan abnormalities > 75%. The risk of HFNC failure could not be predicted by the 6-h ROX index but decreased after a 48-h HFNC duration.

Background Mechanical ventilation (MV) in ICU patients may impact hemodynamics and renal function. We aimed to describe the interactions of MV settings, hemodynamic parameters and worsening of renal function (WRF). Methods We included adult patients admitted for the first time in the ICU from the MIMIC-III database. Mean arterial blood pressure (mABP), central venous pressure (CVP) and positive end-expiratory pressure (PEEP) were collected and summarized as a time-weighted mean. The main outcome was WRF defined as acute kidney injury (AKI) occurrence or one-KDIGO stage worsening compared to the KDIGO stage the day before. We used a multinomial logistic regression at day 1 (ldmk-1) and day 2 (ldmk-2) according to a landmark-approach, with a two-days sliding perspective. Results 27,248/61,051 patients met the inclusion criteria (15,258 male (56.0%); 60.1% over 60 y). ICU and hospital mortality were 7.4 and 10.7%, respectively. MV was independently associated with WRF in the ldmrk-1 and -2 models (relative risk ratio [RRR] 8.15 [6.58;10.11] and 7.08 [3.97;12.61] at day-3 and 4, respectively). In MV patients, PEEP was associated with WRF in the ldmrk-1 and -2 models (RRR 1.36 [1.16, 1.6] and 1.17 [0.88, 1.56] by 1 cmH2O increase at day-3 and 4, respectively). Mean perfusion pressure decreased while central venous pressure increased over PEEP categories. In multivariable analysis, mABP, CVP and PEEP were independently associated with WRF. Conclusion In this large cohort of ICU patients, we observed a strong relationship between MV and WRF. PEEP was associated with WRF in MV patients. This association relied at least partly on renal venous congestion.

Data are scarce on respiratory infections during severe acute exacerbation of chronic obstructive pulmonary disease (COPD). This study aimed to investigate respiratory infection patterns in the intensive care unit (ICU) and identify variables associated with infection type and patient outcome. A retrospective, single-centre cohort study. All patients admitted (2015-2021) to our ICU for severe acute exacerbation of COPD were included. Logistic multivariable regression analysis was performed to predict factors associated with infection and assess the association between infection and outcome. We included 473 patients: 288 (60.9%) had respiratory infection and 139 (29.4%) required invasive mechanical ventilation. Eighty-nine (30.9%) had viral, 81 (28.1%) bacterial, 34 (11.8%) mixed, and 84 (29.2%) undocumented infections. Forty-seven (9.9%) patients died in the ICU and 67 (14.2%) in hospital. Factors associated with respiratory infection were temperature (odds ratio [+1°C]=1.43, 0.008) and blood neutrophils (1.07, 0.002). Male sex (2.21, 0.02) and blood neutrophils were associated with bacterial infection (1.06, 0.04). In a multivariable analysis, pneumonia (cause-specific hazard=1.75, 0.005), respiratory rate (1.17, =0.04), arterial partial pressure of carbon-dioxide (1.08, 0.04), and lactate (1.14, 0.02) were associated with the need for invasive MV. Age (1.03, 0.03), immunodeficiency (1.96, 0.02), and altered performance status (1.78, 0.002) were associated with hospital mortality. Respiratory infections, 39.9% of which were bacterial, were the main cause of severe acute exacerbation of COPD. Body temperature and blood neutrophils were single markers of infection. Pneumonia was associated with the need for invasive mechanical ventilation but not with hospital mortality, as opposed to age, immunodeficiency, and altered performance status.

Data on withholding life-support (WLS) decisions during acute exacerbations of chronic obstructive pulmonary disease (COPD) in the intensive care unit (ICU) are scarce. This study aimed to identify factors associated with these decisions and their impact on mortality. We conducted a monocentric retrospective cohort study on all patients admitted to our ICU between 2015 and 2021 for a severe acute exacerbation of COPD. Logistic multivariable regression analysis was performed. We included 463 patients of whom 128 (27.6%) had a decision of withholding of care. The 3-months mortality was 49.2% and 4.8% in the WLS group and in the no WLS group, respectively. Forty-eight patients (10.4%) had advanced healthcare directives. In multivariable analysis, factors associated with a decision of WLS were higher age (odds ratio [+10 years] = 1.93, < 0.001), immunodeficiency (OR = 3.07, < 0.001), higher Performance Status (PS) score (OR [+1 point] = 2.10, < 0.001), long-term oxygen therapy (OR = 4.11, < 0.001) and shock after ICU admission (OR = 2.43, = 0.01). In multivariate analysis, factors significantly associated with 3-month mortality included decision of WLS during ICU (OR = 22.98, < 0.001) and invasive mechanical ventilation (OR = 2.72, p < 0.001). Approximately 30% of COPD patients underwent a decision to withhold life-sustaining treatment. Higher age, immunosuppression, increased PS score, and long-term oxygen therapy were significantly associated with this decision. Nearly half of the patients died within three months following a withholding of care decision.

The adequacy of initial antimicrobial treatment is a strong determinant of prognosis in septic shock. The prototypic synergistic combination of beta-lactams with aminoglycosides appears as an attractive therapeutic option, but its actual benefit remains elusive [1, 2]. We took advantage of a large comprehensive cohort of septic shock to address the impact of aminoglycosides on mortality, with respect to their pharmacodynamic and pharmacokinetic properties.

We conducted a retrospective study on hemolytic uremic syndrome caused by Shiga toxin–producing Escherichia coli (STEC) in 96 adults enrolled in the cohort of the National Reference Center for Thrombotic Microangiopathies network in France during 2009–2017. Most infections were caused by STEC strains not belonging to the O157 or O104 serogroups. Thirty (31.3%) patients had multiple risk factors for thrombotic microangiopathy. In total, 61 (63.5%) patients required dialysis, 50 (52.1%) had a serious neurologic complication, 34 (35.4%) required mechanical ventilation, and 19 (19.8%) died during hospitalization. We used multivariate analysis to determine that the greatest risk factors for death were underlying immunodeficiency (hazard ratio 3.54) and severe neurologic events (hazard ratio 3.40). According to multivariate analysis and propensity score-matching, eculizumab treatment was not associated with survival. We found that underlying conditions, especially immunodeficiency, are strongly associated with decreased survival in adults who have hemolytic uremic syndrome caused by STEC.