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Background The importance of assessing venous congestion in ICU patients is widely acknowledged, but its study is hampered by the lack of a practical evaluation tool. The Venous Excess Ultrasound Grading System (VExUS), based on a semi-quantitative combined ultrasound assessment, has been associated with acute kidney injury (AKI) in cardiac ICU patients. The objectives of this study were to assess the prevalence of congestion using VExUS in general ICU patients, and to evaluate the association between VExUS, AKI and death. Methods This prospective, observational study included adult patients within 24 h of ICU admission. VExUS and hemodynamic parameters were measured four times during the ICU stay: within 24 h of ICU admission, after day 1 (between 24 and 48 h), after day 2 (between 48 and 72 h), and last day of ICU stay. The prevalence of AKI during the first week in ICU and 28-day mortality were assessed. Results Among the 145 patients included, the percentage of patients with a VExUS score of 2 (moderate congestion) and 3 (severe congestion) was 16% and 6%, respectively. The prevalence did not change over the study period. There was no significant association between admission VExUS scores and AKI ( p  = 0.136) or 28-day mortality ( p  = 0.594). Admission VExUS ≥ 2 was not associated with AKI (OR 0.499, CI 95% 0.21–1.17, p  = 0.109) nor 28-day mortality (OR 0.75, CI 95% 0.2–2.8, p  = 0.669). The results were similar for VExUS scores measured at day 1 and day 2. Conclusions In general ICU cohort the prevalence of moderate to severe venous congestion was low. Early assessment of systemic venous congestion using VExUS scores was not associated with the development of AKI or with 28-day mortality.

Hip fracture (HF) remains a main issue in the elderly patient. About 1.6 million patients a year worldwide are victims of a HF. Their incidence is expected to rise with the aging of the world’s population. Identifying risk factors is mandatory in order to reduce mortality and morbidity. The aim of the study was to identify risk factors of 1-year mortality after HF surgery. We performed an observational, prospective, single-center study at Amiens University Hospital (Amiens, France). After ethical approval, we consecutively included all patients with a HF who underwent surgery between June 2016 and June 2017. Perioperative data were collected from medical charts and by interviews. Mortality rate at 12 months was recorded. Univariate analysis was performed and mortality risk factors were investigated using a Cox model. 309 patients were analyzed during this follow-up. Mortality at 1 year was 23.9%. Time to surgery over 48 hours involved 181 patients (58.6%) while 128 patients (41.4%) had surgery within the 48 hours following the hospital admission. Independent factors associated with 1-year mortality were: age (HR at 1.059 (95%CI [1.005–1.116], p = 0,032), Lee score ≥ 3 (HR at 1,52 (95% CI [1,052–2,198], p = 0.026) and time to surgery over 48 hours (HR of 1.057 (95% CI [1.007–1.108], p = 0.024). Age, delayed surgical (over 48 hours) management and medical history are important risk factors of 1-year mortality in this French cohort

PurposeWeaning failure from mechanical ventilation may be due to lung de-recruitment or weaning-induced pulmonary oedema (WIPO). Both can be diagnosed by lung ultrasound (LUS) and transthoracic echocardiography (TTE), respectively. We conducted a prospective observational study, combining TTE and LUS, to determine if LUS alone may identify elderly patients at high risk of weaning or extubation failure.MethodsBefore and at the end of spontaneous breathing trials (SBT) in 40 elderly patients, we prospectively performed LUS and TTE. Extubation was decided by an independent operator. LUS included global and anterolateral LUS score. TTE included measurement of E/A and E/Ea ratios to determine LV filling pressures. SBT LUS scores for prediction of weaning outcome and for the diagnosis of WIPO were studied.ResultsWeaning or extubation failure was observed in 45% (95% CI 28–61) of patients. ROC analysis for ability of global SBT LUS to predict weaning/extubation failure and extubation failure found AUC of 0.80 and 0.81, respectively. AUC for anterolateral SBT LUS to predict weaning/extubation failure and extubation failure was 0.79 and 0.81, respectively. Increased LV filling pressure during SBT was observed without increase of anterolateral LUS score. Inversely, increase of anterolateral LUS was observed without increased filling pressure and was associated with extubation failure. Global and anterolateral SBT LUS were not correlated to E/Ea.ConclusionIn elderly patients, global and anterolateral LUS scores were associated with weaning and extubation failures while echocardiographic indices of filling pressures were not.Clinical trial number and registry URLClinicalTrials.gov No. NCT03261440.

Background Fluid overload and venous congestion are associated with morbi-mortality in the ICU (intensive care unit). Administration of diuretics to correct the fluid balance is common, although there is no strong relationship between the consequent fluid loss and clinical improvement. The aim of the study was to evaluate the ability of the portal pulsatility index, the renal venous impedance index, and the VEXUS score (venous ultrasound congestion score) to predict appropriate diuretic-induced fluid depletion. Methods The study had a prospective, observational, single-center observational design and was conducted in a university-affiliated medico-surgical ICU. Adult patients for whom the clinician decided to introduce loop diuretic treatment were included. Hemodynamic and ultrasound measurements (including the portal pulsatility index, renal venous impedance index and VEXUS score) were performed at inclusion and 2 hours after the initiation of the diuretics. The patients’ characteristics were noted at inclusion, 24 h later, and at ICU discharge. The appropriate diuretic-induced fluid depletion was defined by a congestive score lower than 3 after diuretic fluid depletion. The congestive score included clinical and biological parameters of congestion. Results Eighty-one patients were included, and 43 (53%) patients presented with clinically significant congestion score at inclusion. Thirty-four patients (42%) had an appropriate response to diuretic-induced fluid depletion. None of the left- and right-sided echocardiographic parameters differed between the two groups. The baseline portal pulsatility index was the best predictor of appropriate response to diuretic-induced fluid depletion (AUC = 0.80, CI 95% :0.70–0.92, p  = 0.001), followed by the renal venous impedance index (AUC = 0.72, CI 95% 0.61–0.84, p  = 0.001). The baseline VEXUS score (AUC of 0.66 CI 95% 0.53–0.79, p  = 0.012) was poorly predictive of appropriate response to diuretic-induced fluid depletion. Conclusion The portal pulsatility index and the renal venous impedance index were predictive of the appropriate response to diuretic-induced fluid depletion in ICU patients. The portal pulsatility index should be evaluated in future randomized studies.

During refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (P POST O 2 ) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this P POST O 2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (F S O 2 ). Because of the oxygenator’s performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO 2 ) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting F S O 2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of P POST O 2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.

[...]understanding the hemodynamic response to vasopressin in this specific patient population may be important. [...]the small number of survivors reduced the power of our analysis. [...]the reporting of cardiac index and cardiac contractility monitoring would have provided a better understanding of the ventriculo-arterial coupling phenomenon, which appears to be a central issue in this population.

BackgroundThe potential influence of thoracic ultrasound on clinical decision-making by physiotherapists has never been studied. The aim of this study was to assess the impact of thoracic ultrasound on clinical decision-making by physiotherapists for critical care patients.MethodsThis prospective, observational multicentre study was conducted between May 2017 and November 2020 in four intensive care units in France and Australia. All hypoxemic patients consecutively admitted were enrolled. The primary outcome was the net reclassification improvement (NRI), quantifying how well the new model (physiotherapist’s clinical decision-making including thoracic ultrasound) reclassifies subjects as compared with an old model (clinical assessment). Secondary outcomes were the factors associated with diagnostic concordance and physiotherapy treatment modification.ResultsA total of 151 patients were included in the analysis. The NRI for the modification of physiotherapist’s clinical decisions was—40% (95% CI (−56 to −22%), p=0.02). Among the cases in which treatment was changed after ultrasound, 41% of changes were major (n=38). Using a multivariate analysis, the physiotherapist’s confidence in their clinical diagnosis was associated with diagnostic concordance (adjusted OR=3.28 95% CI (1.30 to 8.71); p=0.014). Clinical diagnosis involving non-parenchymal conditions and clinical signs reflecting abolished lung ventilation were associated with diagnostic discordance (adjusted OR=0.06 95% CI (0.01 to 0.26), p<0.001; adjusted OR=0.26 95% CI (0.09 to 0.69), p=0.008; respectively).ConclusionThoracic ultrasound has a high impact on the clinical decision-making process by physiotherapists for critical care patients.Trial registration number NCT02881814; https://clinicaltrials.gov.

We aimed to evaluate the prognostic value of octanoyl-carnitine in patients undergoing surgical myocardial revascularization for coronary artery disease. We conducted a retrospective analysis of an existing prospective cohort aimed at studying risk factors for vasoplegia in patients undergoing cardiac surgery with cardiopulmonary bypass. We conducted our study exclusively on patients included in the prospective cohort at Dijon University Hospital in 2021. We included 42 adult patients undergoing coronary artery bypass grafting, either alone or combined with another surgical procedure. We collected plasma samples for each patient from EDTA-anticoagulated tubes, taken as part of routine biological check-ups according to the department protocol, at three time points: preoperatively, immediately postoperatively in the intensive care unit, and on the first postoperative day. Liquid chromatography coupled with tandem mass spectrometry was used to determine plasma levels of acyl-carnitines, including octanoyl-carnitine. The primary endpoint was the occurrence of major postoperative complications (stroke, atrial fibrillation, acute kidney injury, and/or death). Fourteen patients (33%) had major postoperative complications. Octanoyl-carnitine plasma concentration significantly increased during the perioperative period and was significantly associated with major postoperative complications at all three time points in coronary artery bypass grafting patients (T1: 14.2 [11.6; 18.6] vs 21.1 [14.8; 28.0], T2: 20.9 [16.4;27.9] vs 34.8 [21.2;37.2], T3: 22.8 [13.7;30.9] vs 34.4 [30.2;41.2]; p  < 0.05; in nmol/l). At baseline, octanoyl-carnitine levels were higher in patients with complications, while other acyl-carnitines showed no significant differences. Octanoyl-carnitine is associated with mitochondrial metabolism and could be evaluated alone or in conjunction with clinical scores.

Background The mortality rate for a patient with a refractory cardiogenic shock on venoarterial (VA) extracorporeal membrane oxygenation (ECMO) remains high, and hyperoxia might worsen this prognosis. The objective of the present study was to evaluate the association between hyperoxia and 28-day mortality in this setting. Methods We conducted a retrospective bicenter study in two French academic centers. The study population comprised adult patients admitted for refractory cardiogenic shock. The following arterial partial pressure of oxygen (PaO 2 ) variables were recorded for 48 h following admission: the absolute peak PaO 2 (the single highest value measured during the 48 h), the mean daily peak PaO 2 (the mean of each day’s peak values), the overall mean PaO 2 (the mean of all values over 48 h), and the severity of hyperoxia (mild: PaO 2  < 200 mmHg, moderate: PaO 2  = 200–299 mmHg, severe: PaO 2  ≥ 300 mmHg). The main outcome was the 28-day all-cause mortality. Inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalances in baseline characteristics. Results From January 2013 to January 2020, 430 patients were included and assessed. The 28-day mortality rate was 43%. The mean daily peak, absolute peak, and overall mean PaO 2 values were significantly higher in non-survivors than in survivors. In a multivariate logistic regression analysis, the mean daily peak PaO 2 , absolute peak PaO 2 , and overall mean PaO 2 were independent predictors of 28-day mortality (adjusted odds ratio [95% confidence interval per 10 mmHg increment: 2.65 [1.79–6.07], 2.36 [1.67–4.82], and 2.85 [1.12–7.37], respectively). After IPW, high level of oxygen remained significantly associated with 28-day mortality (OR = 1.41 [1.01–2.08]; P  = 0.041). Conclusions High oxygen levels were associated with 28-day mortality in patients on VA-ECMO support for refractory cardiogenic shock. Our results confirm the need for large randomized controlled trials on this topic.

PurposeData on the benefit or or harmful effects of oxygen level on ischemic reperfusion injuries in cardiac surgery are insufficient. We hypothesized that hyperoxia during cardiopulmonary bypass decreases the incidence of postoperative atrial fibrillation (POAF) and ventricular fibrillation, and therefore decreases cardiovascular morbidity (CARDIOX study).MethodsAn open-label, randomized clinical trial including adults undergoing elective cardiac surgery, i.e. cardiopulmonary bypass (CPB) randomized 1:1 to an intervention group or standard group at two French University Hospitals from June 2016 to October 2018. The intervention consisted in delivering of an inspired fraction of oxygen of one to one during CPB. The standard care consisted in delivering oxygen to achieve a partial arterial blood pressure less than 150 mmHg. The primary endpoint was the occurrence of POAF and/or ventricular tachycardia/ventricular fibrillation (VT/VF) within the 15 days following cardiac surgery. The secondary endpoint was the occurrence of major adverse cardiovascular events (MACCE: in-hospital mortality, stroke, cardiac arrest, acute kidney injury, and mesenteric ischemia).Results330 patients were randomly assigned to either the intervention group (n = 161) or the standard group (n = 163). Mean PaO2 was 447 ± 98 mmHg and 161 ± 60 mmHg during CPB, for the intervention and standard group (p < 0.0001) respectively. The incidence of POAF or VT/VF were similar in the intervention group and the standard group (30% [49 of 161 patients] and 30% [49 of 163 patients], absolute risk reduction 0.4%; 95% CI, − 9.6–10.4; p = 0.94). MACCE was similar between groups with, an occurrence of 24% and 21% for the intervention group and the standard groups (absolute risk reduction 3.4%; 95% CI, − 5.7–12.5; p = 0.47) respectively. After adjustment, the primary and secondary endpoints remained similar for both groups.ConclusionHyperoxia did not decrease POAF and cardiovascular morbidity following cardiac surgery with CPB.Clinicaltrial.gov identifierNCT02819739.