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Purpose The primary objective of this study was to investigate the risk of ICU bloodstream infection (BSI) in critically ill COVID-19 patients compared to non-COVID-19 patients. Subsequently, we performed secondary analyses in order to explain the observed results. Methods We conducted a matched case-cohort study, based on prospectively collected data from a large ICU cohort in France. Critically ill COVID-19 patients were matched with similar non-COVID-19 patients. ICU-BSI was defined by an infection onset occurring > 48 h after ICU admission. We estimated the effect of COVID-19 on the probability to develop an ICU-BSI using proportional subdistribution hazards models. Results We identified 321 COVID-19 patients and 1029 eligible controls in 6 ICUs. Finally, 235 COVID-19 patients were matched with 235 non-COVID-19 patients. We observed 43 ICU-BSIs, 35 (14.9%) in the COVID-19 group and 8 (3.4%) in the non-COVID-19 group ( p  ≤ 0.0001), respectively. ICU-BSIs of COVID-19 patients were more frequently of unknown source (47.4%). COVID-19 patients had an increased probability to develop ICU-BSI, especially after 7 days of ICU admission. Using proportional subdistribution hazards models, COVID-19 increased the daily risk to develop ICU-BSI (sHR 4.50, 95% CI 1.82–11.16, p  = 0.0012). Among COVID-19 patients ( n  = 235), a significantly increased risk for ICU-BSI was detected in patients who received tocilizumab or anakinra (sHR 3.20, 95% CI 1.31–7.81, p  = 0.011) but not corticosteroids. Conclusions Using prospectively collected multicentric data, we showed that the ICU-BSI risk was higher for COVID-19 than non-COVID-19 critically ill patients after seven days of ICU stay. Clinicians should be particularly careful on late ICU-BSIs in COVID-19 patients. Tocilizumab or anakinra may increase the ICU-BSI risk.

Patients in the ICU were assigned to catheter insertion in the subclavian, jugular, or femoral vein. Subclavian catheterization had a lower risk of bloodstream infection and deep-vein thrombosis, and a higher risk of pneumothorax, than catheterization in the other two sites. Subclavian, jugular, and femoral central venous catheterization are associated with infectious, thrombotic, and mechanical complications. 1 Catheter-related bloodstream infection has a significant effect on morbidity, mortality, and health care costs. 2 – 4 The risk of short-term catheter-related bloodstream infection is influenced mainly by extraluminal microbial colonization of the insertion site, 5 and such colonization is also associated with thrombosis. 6 , 7 Although the importance of catheter-related deep-vein thrombosis has been debated, 1 all thromboses have the potential to embolize. In addition, catheter-related deep-vein thrombosis 7 – 9 and pulmonary embolism 10 may remain undiagnosed in critically ill patients undergoing mechanical ventilation. 11 We conducted the 3SITES multicenter study to . . .

Background In immunocompromised patients with acute hypoxemic respiratory failure (ARF), initial management aims primarily to avoid invasive mechanical ventilation (IMV). Methods To assess the impact of initial management on IMV and mortality rates, we performed a multinational observational prospective cohort study in 16 countries (68 centers). Results A total of 1611 patients were enrolled (hematological malignancies 51.9%, solid tumors 35.2%, systemic diseases 17.3%, and solid organ transplantation 8.8%). The main ARF etiologies were bacterial (29.5%), viral (15.4%), and fungal infections (14.7%), or undetermined (13.2%). On admission, 915 (56.8%) patients were not intubated. They received standard oxygen ( N  = 496, 53.9%), high-flow oxygen (HFNC, N  = 187, 20.3%), noninvasive ventilation (NIV, N  = 153, 17.2%), and NIV + HFNC ( N  = 79, 8.6%). Factors associated with IMV included age (hazard ratio = 0.92/year, 95% CI 0.86–0.99), day-1 SOFA (1.09/point, 1.06–1.13), day-1 PaO 2 /FiO 2 (1.47, 1.05–2.07), ARF etiology ( Pneumocystis jirovecii pneumonia (2.11, 1.42–3.14), invasive pulmonary aspergillosis (1.85, 1.21–2.85), and undetermined cause (1.46, 1.09–1.98). After propensity score matching, HFNC, but not NIV, had an effect on IMV rate (HR = 0.77, 95% CI 0.59–1.00, p  = 0.05). ICU, hospital, and day-90 mortality rates were 32.4, 44.1, and 56.4%, respectively. Factors independently associated with hospital mortality included age (odds ratio = 1.18/year, 1.09–1.27), direct admission to the ICU (0.69, 0.54–0.87), day-1 SOFA excluding respiratory score (1.12/point, 1.08–1.16), PaO 2 /FiO 2  < 100 (1.60, 1.03–2.48), and undetermined ARF etiology (1.43, 1.04–1.97). Initial oxygenation strategy did not affect mortality; however, IMV was associated with mortality, the odds ratio depending on IMV conditions: NIV + HFNC failure (2.31, 1.09–4.91), first-line IMV (2.55, 1.94–3.29), NIV failure (3.65, 2.05–6.53), standard oxygen failure (4.16, 2.91–5.93), and HFNC failure (5.54, 3.27–9.38). Conclusion HFNC has an effect on intubation but not on mortality rates. Failure to identify ARF etiology is associated with higher rates of both intubation and mortality. This suggests that in addition to selecting the appropriate oxygenation device, clinicians should strive to identify the etiology of ARF.

Our goal was to investigate the effects of head-thorax elevation (HUP) during chest compressions (CC) on lung ventilation. A prospective study was performed on seven human cadavers. Chest was automatically compressed-decompressed in flat position and during progressive HUP from 18 to 35°. Lung ventilation was measured with electrical impedance tomography. In each cadaver, 5 sequences were randomly performed: one without CC at positive end-expiratory pressure (PEEP) 0cmH 2 O, 3 s with CC at PEEP0, 5 or 10cmH 2 O and 1 with CC and an impedance threshold device at PEEP0cmH 2 O. The minimal-to-maximal change in impedance (VT EIT in arbitrary unit a.u.) and the minimal impedance in every breathing cycle (EELI) the) were compared between flat, 18°, and 35° in each sequence by a mixed-effects model. Values are expressed as median (1st–3rd quartiles). With CC, between flat, 18° and 35° VT EIT decreased at each level of PEEP. It was 12416a.u. (10,689; 14,442), 11,239 (7667; 13,292), and 6457 (4631; 9516), respectively, at PEEP0. The same was true with the impedance threshold device. EELI/VT EIT significantly decreased from − 0.30 (− 0.40; − 0.15) before to − 1.13 (− 1.70; − 0.61) after the CC (P = 0.009). With HUP lung ventilation decreased with CC as compared to flat position. CC are associated with decreased in EELI.

Background The incidence of obesity among patients admitted to the intensive care unit (ICU) is increasing, and pneumonia remains the leading cause of acute respiratory distress syndrome (ARDS). The association of obesity on both short- and long-term outcomes in patients with pneumonia-induced ARDS has been the subject of only limited research. Methods We conducted a retrospective analysis of a prospective cohort consisting of ARDS patients who had microbiologically confirmed pneumonia and a PaO 2 /FiO 2 ratio ≤ 150 mmHg. Patients were assessed for mortality at 28 days, 90 days, and at 1 year from the diagnosis of ARDS and compared between obese defined by a body mass index (BMI) ≥ 30 kg.m 2 and non-obese patients. Models were adjusted for age, sex, COPD, coronary artery disease, immunodepression, severity score and acute kidney injury on admission to the ICU, severity of ARDS (PaO 2 /FiO 2 ratio ≤ 100 mmHg), severe hypercapnia (PaCO 2  ≥ 50 mmHg), ventilatory ratio and plateau pressure the first day of ARDS, influenza, COVID-19, pneumocystosis, and bacteria involved in pneumonia. We also investigated the continuous spectrum of BMI on the risk of mortality. Results Of 603 patients, 227 patients (37.6%) were obese. Obesity was associated with female gender ( p  = 0.009), hypertension ( p  < 0.001), diabetes mellitus ( p  < 0.001), COVID-19 pneumonia ( p  = 0.008), and PaO2/FiO2 ratio ≤ 100 mmHg ( p  = 0.006). Obesity was independently associated with lower mortality at 28 days (adjusted Odds Ratio (OR) 0.55, 95% confident interval (CI) 0.33–0.90, p  = 0.02) but not at 90 days (adjusted OR 0.70, 95% CI 0.45–1.09, p  = 0.11) nor at 1 year from the diagnosis of ARDS (adjusted OR 0.73, 95% CI 0.47–1.13, p  = 0.16). Mortality at 28 days was significantly lower in obese patients than in non-obese patients when propensity score matching was used (15.2% versus 22%, p = 0.04). BMI was also independently associated with lower mortality at 28 days ( p  = 0.038) but not with mortality at 90 days ( p  = 0.12) and 1 year ( p  = 0.12). Conclusion Our results suggest that in patients with pneumonia-related ARDS, obesity is independently associated with better survival at 28 days but not at 90 days and 1 year from the diagnosis of ARDS.

When patients with acute respiratory distress syndrome are moved out of an intensive care unit, the ventilator often requires changing. This procedure suppresses positive end expiratory pressure and promotes lung derecruitment. Clamping the endotracheal tube may prevent this from occurring. Whether or not such clamping maintains positive end-expiratory pressure has never been investigated. We designed a bench study to explore this further. We used the Elysee 350 ventilator in 'volume controlled' mode with a positive end-expiratory pressure of 15 cmH2O, connected to an endotracheal tube with an 8 mm internal diameter inserted into a lung model with 40 ml/cmH2O compliance and 10 cmH2O/L/s resistance. We measured airway pressure and flow between the distal end of the endotracheal tube and the lung model. We tested a plastic, a metal, and an Extra Corporeal Membrane Oxygenation clamp, each with an oral/nasal, a nasal, and a reinforced endotracheal tube. We performed an end-expiratory hold then clamped the endotracheal tube and disconnected the ventilator. We measured the change in airway pressure and volume for 30 s following the disconnection of the ventilator. Airway pressure decreased thirty seconds after disconnection with all combinations of clamp and endotracheal tube. The largest fall in airway pressure (-17.486 cmH2O/s at 5 s and -18.834 cmH2O/s at 30 s) was observed with the plastic clamp combined with the reinforced endotracheal tube. The smallest decrease in airway pressure (0 cmH2O/s at 5 s and -0.163 cmH2O/s at 30 s) was observed using the Extra Corporeal Membrane Oxygenation clamp with the nasal endotracheal tube. Only the Extra Corporeal Membrane Oxygenation clamp was efficient. Even with an Extra Corporeal Membrane Oxygenation clamp, it is important to limit the duration the ventilator is disconnected to a few seconds (ideally 5 s).

Background At intensive care unit (ICU) admission, the issue about prognosis of critically ill cancer patients is of clinical interest, especially after ICU discharge. Our objective was to assess the factors associated with 3- and 6-month survival of ICU cancer survivors. Methods Based on the French OutcomeRea™ database, we included solid cancer patients discharged alive, between December 2005 and November 2013, from the medical ICU of the university hospital in Grenoble, France. Patient characteristics and outcome at 3 and 6 months following ICU discharge were extracted from available database. Results Of the 361 cancer patients with unscheduled admissions, 253 (70%) were discharged alive from ICU. The main primary cancer sites were digestive (31%) and thoracic (26%). The 3- and 6-month mortality rates were 33 and 41%, respectively. Factors independently associated with 6-month mortality included ECOG performance status (ECOG-PS) of 3–4 (OR,3.74; 95%CI: 1.67–8.37), metastatic disease (OR,2.56; 95%CI: 1.34–4.90), admission for cancer progression (OR,2.31; 95%CI: 1.14–4.68), SAPS II of 45 to 58 (OR,4.19; 95%CI: 1.76–9.97), and treatment limitation decision at ICU admission (OR,4.00; 95%CI: 1.64–9.77). Interestingly, previous cancer chemotherapy prior to ICU admission was independently associated with lower 3-month mortality (OR, 0.38; 95%CI: 0.19–0.75). Among patients with an ECOG-PS 0–1 at admission, 70% ( n  = 66) and 61% ( n  = 57) displayed an ECOG-PS 0–2 at 3- and 6-months, respectively. At 3 months, 74 (55%) patients received anticancer treatment, 13 (8%) were given exclusive palliative care. Conclusions Factors associated with 6-month mortality are almost the same as those known to be associated with ICU mortality. We highlight that most patients recovered an ECOG-PS of 0–2 at 3 and 6 months, in particular those with a good ECOG-PS at ICU admission and could benefit from an anticancer treatment following ICU discharge.

Background Patients with ARDS have heterogeneous lungs which exposes them to the risk of lung injury exacerbation by mechanical ventilation. Functional lung CT imaging gives a comprehensive description of regional lung mechanical behaviour. Here, we investigated whether CT registration-based regional lung function parameters are associated with survival in patients with COVID-ARDS. Methods We conducted a two-centre prospective observational study of adult COVID-ARDS patients with an indication for CT within 72 h of onset. Dual volume CT images were aligned using image-registration. Regional lung functional parameters, and their spatial distributions, were analysed by univariable Cox proportional hazard models with survival as the main outcome. Selected variables based on the univariable analysis were included in a stepwise Cox model adjusted for age, sex, body mass index and SAPSII. Results 94 patients were included in the study. Recruitment was associated with a higher (HR = 1.45, p  = 0.023) hazard of death, while apical (sΔV z ) and central (sΔV x ) displacement of specific volume change centre-of-mass were associated with a lower hazard of death (HR = 0.72, p  = 0.041; HR = 0.68, p  = 0.031, respectively). Conclusions Our data show that in addition to recruitment, the spatial distribution of specific volume change, a surrogate measure of regional lung ventilation, is associated with the risk of death in mechanically ventilated COVID-19 ARDS patients. Our findings suggest that CT image-registration based functional biomarkers may have prognostic value in COVID-ARDS patients. Trial registration This study was retrospectively registered in Clinical Trials under NCT06113276 ( https://clinicaltrials.gov/study/NCT06113276 ) on 27/10/2023.

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a frequent cause of intensive care unit (ICU) admission. However, data are scarce and conflicting regarding the impact of systemic corticosteroid treatment in critically ill patients with acute exacerbation of COPD. The aim of the study was to assess the impact of systemic corticosteroids on the occurrence of death or need for continuous invasive mechanical ventilation at day 28 after ICU admission. In the OutcomeReaTM prospective French national ICU database, we assessed the impact of corticosteroids at admission (daily dose ≥ 0.5 mg/kg of prednisone or equivalent during the first 24 hours ICU stay) on a composite outcome (death or invasive mechanical ventilation) using an inverse probability treatment weighting. Between January 1, 1997 and December 31, 2018, 391 out of 1,247 patients with acute exacerbations of COPDs received corticosteroids at ICU admission. Corticosteroids improved the main composite endpoint (OR = 0.70 [0.49; 0.99], p = 0.044. However, for the subgroup of most severe COPD patients, this did not occur (OR = 1.12 [0.53; 2.36], p = 0. 770). There was no significant impact of corticosteroids on rates of non-invasive ventilation failure, length of ICU or hospital stay, mortality or on the duration of mechanical ventilation. Patients on corticosteroids had the same prevalence of nosocomial infections as those without corticosteroids, but more glycaemic disorders. Using systemic corticosteroids for acute exacerbation of COPD at ICU admission had a positive effect on a composite outcome defined by death or need for invasive mechanical ventilation at day 28.