Background:The diagnosis of acute mesenteric ischemia (AMI) is challenging, especially in the intensive care unit (ICU), where non-occlusive mesenteric ischemia (NOMI) predominates. In ICU patients, contrast-enhanced computed tomography (CT) provides limited diagnostic accuracy, and no single biomarker is sufficiently reliable. Transmural digestive necrosis, revealed as necrotic bowel (NB) during surgical exploration, is irreversible and requires bowel resection. We proposed an approach combining several clinical, biological, and therapeutic parameters to predict the presence of NB in ICU patients with high suspicion of AMI. Methods:We conducted a prospective observational study in three ICUs. All consecutive patients with suspected AMI were enrolled. Patients with NB identified during surgical exploration were compared with those without NB. Patients who survived without undergoing surgery were considered not to have NB. Multivariable logistic regression analysis was used to identify parameters independently associated with NB. Results:A total of 202 patients were included. Among them, 74 (37%) had NB (including 70 with NOMI and 4 with occlusive AMI), while 128 (63%) did not. In the multivariable analysis, age (OR 1.068, 95% CI 1.027-1.111, p = 0.001), active fluid removal (OR 3.148 (1.19-8.33), p = 0.021), signs of gastrointestinal injury (3.432 (1.082-10.885), p = 0.036), need for renal replacement therapy (OR 3.834 (1.457-10.01), p = 0.006), and lactate dehydrogenase (log) at the time of AMI suspicion (OR 7.135 (2.1-24.235) p = 0.002) were independently associated with NB. Among biomarkers, lactate dehydrogenase, showed the highest area under the ROC curve. Conclusions:This is the first study to propose a combined approach for predicting NB in ICU patients with suspected AMI. When AMI is highly suspected, surgical exploration should be considered in patients presenting with signs of gastrointestinal injury in a context of fluid removal or renal replacement therapy, as these findings are strongly suggestive of necrotic bowel.

Recent changes in the mycological profile have been reported in several life-threatening infections, but no data have assessed this issue in postoperative peritonitis (POP). This retrospective monocentric analysis (1999–2019) evaluated the temporal changes of fungi collected from POP samples in intensive care unit (ICU) patients and assessed the adequacy of antifungal therapy (AFT) and the prognosis. Overall, 1,389 microorganisms were cultured from surgical samples in 464 ICU patients, including 186 (40

OBJECTIVES:Uric acid (UA) concentration is associated with increased risk of atrial fibrillation, but few studies have investigated this association after cardiac surgery. This study investigated the statistical association between postoperative atrial fibrillation (POAF) and preoperative UA concentration according to the type of cardiac surgery. METHODS:Consecutive patients undergoing cardiac surgery at a tertiary center from January to May 2019 were eligible. Patients were separated into two groups according to POAF occurrence. Subgroup analyses were performed in patients undergoing coronary artery bypass grafting (CABG) or valve surgery. Binary logistic regression models were used to assess independent factors of POAF. Principal component analyses (PCA) were performed to investigate whether CABG or valve surgeries were associated with different biological profiles for POAF. RESULTS:The study included 221 patients, of whom 76 experienced at least one POAF episode. The UA concentration was higher in the POAF group compared with the POAF-free group (352 μmol/l [295-420] vs. 321 μmol/l [249-380], p = 0.004). This association persisted in multivariable analysis (for 10 μmol, odds ratio = 1.04 [1.34-8,7], p = 0.014) and in patients undergoing isolated CABG. In patients undergoing valve surgery, despite a high incidence of POAF, no association was found. PCA identified different blood biological profiles associated with POAF after CABG vs. valve surgery. CONCLUSION:The preoperative UA concentration was independently associated with the occurrence of POAF after CABG but not after valve surgery. PCA results indicate that different biological profiles contribute to POAF occurrence according to the type of cardiac surgery, thus suggesting different strategies for prevention/intervention.

Anticoagulation in patients with mechanical heart valves (MHV) is associated with a risk of major bleeding episodes (MBE). In case of MBE, anticoagulant interruption is advocated. However, there is lack of data regarding the thrombo-embolic events (TE) risk associated with anticoagulant interruption. The main objective of the study was to evaluate the rate and risk factors of 6-months of TEs in patients with MHV experiencing MBE. This observational study was conducted over a 13-year period. Adult patients with a MHV presenting with a MBE were included. The main study endpoint was 6-month TEs, defined by clinical TEs or an echocardiographic documented thrombosis, occurring during an ICU stay or within 6-months. Thromboembolic events were recorded at ICU discharge, and 6 months after discharge. Seventy-nine MBEs were analysed, the rate of TEs at 6-months was 19

Background Temporal changes in the microbiological resistance profile have been reported in several life-threatening infections. However, no data have ever assessed this issue in postoperative peritonitis (POP). Our purpose was to assess the rate of multidrug-resistant organisms (MDROs) in POP over a two-decade period and to analyse their influence on the adequacy of empirical antibiotic therapy (EAT). Methods This retrospective monocentric analysis (1999–2019) addressed the changes over time in microbiologic data, including the emergence of MDROs and the adequacy of EAT for all intensive care unit adult patients treated for POP. The in vitro activities of 10 antibiotics were assessed to determine the most adequate EAT in the largest number of cases among 17 antibiotic regimens in patients with/without MDRO isolates. Our primary endpoint was to determine the frequency of MDRO and their temporal changes. Our second endpoint assessed the impact of MDROs on the adequacy of EAT per patient and their temporal changes based on susceptibility testing. In this analysis, the subgroup of patients with MDRO was compared with the subgroup of patients free of MDRO. Results A total of 1,318 microorganisms were cultured from 422 patients, including 188 (45%) patients harbouring MDROs. The growing proportions of MDR Enterobacterales were observed over time ( p = 0.016), including ESBL-producing strains ( p = 0.0013), mainly related to Klebsiella spp ( p < 0.001). Adequacy of EAT was achieved in 305 (73%) patients. Decreased adequacy rates were observed when MDROs were cultured [ p = 0.0001 vs. MDRO-free patients]. Over the study period, decreased adequacy rates were reported for patients receiving piperacillin/tazobactam in monotherapy or combined with vancomycin and imipenem/cilastatin combined with vancomycin ( p < 0.01 in the three cases). In patients with MDROs, the combination of imipenem/cilastatin + vancomycin + amikacin or ciprofloxacin reached the highest adequacy rates (95% and 91%, respectively) and remained unchanged over time. Conclusions We observed high proportions of MDRO in patients treated for POP associated with increasing proportions of MDR Enterobacterales over time. High adequacy rates were only achieved in antibiotic combinations involving carbapenems and vancomycin, while piperacillin/tazobactam is no longer a drug of choice for EAT in POP in infections involving MDRO. Graphical Abstract

Background While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. Methods Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. Results Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20–49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%–92%), specificity 93% (90%–97%), positive predictive value (PPV) 60% (49%–83%), negative predictive value (NPV) 97% (93%–99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%–99%), specificity 96% (92%–98%), PPV 83% (63%–93%) and NPV 99% (96%–100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%–97%), specificity 97% (93%–99%), PPV 55% (23%–83%) and NPV 99% (96%–99%). Conclusions In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

An increase in troponin I is common after lung transplantation, but the kinetics of troponin I release have not been studied.1Andrei S Kantor E Asssadi M et al.The prognostic role of early postoperative troponin I in lung transplantation—A retrospective 7-year analysis.J Cardiothorac Vasc Anesth. 2022; 36: 2328-2334Abstract Full Text Full Text PDF Scopus (1) Google Scholar The lung transplant procedure includes technical specificities which may induce troponin release, including direct tissue injury due to left atrial manipulation (clamping, myotomy, sutures), handling of the heart, pulmonary artery clamping, or hemodynamic instability.1Andrei S Kantor E Asssadi M et al.The prognostic role of early postoperative troponin I in lung transplantation—A retrospective 7-year analysis.J Cardiothorac Vasc Anesth. 2022; 36: 2328-2334Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 2Lasocki S Provenchère S Bénessiano J et al.Cardiac troponin I is an independent predictor of in-hospital death after adult cardiac surgery.Anesthesiology. 2002; 97: 405-411Crossref PubMed Scopus (128) Google Scholar, 3Ekeloef S Alamili M Devereaux PJ Gögenur I. Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis.Br J Anaesth. 2016; 117: 559-568Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 4Visser HT Erasmus ME Ebels T. Cardiac luxation to facilitate off-pump bilateral lung transplantation.Ann Thorac Surg. 2007; 83: 329-330Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 5Arango Tomás E Cerezo Madueño F Salvatierra Velázquez A. Technique resource for difficult auricular anastomosis in lung transplantation.Transplant Proc. 2015; 47: 2653-2655Crossref PubMed Scopus (4) Google Scholar, 6Meyer T Binder L Hruska N Luthe H Buchwald AB. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction.J Am Coll Cardiol. 2000; 36: 1632-1636Crossref PubMed Scopus (277) Google Scholar In this pilot study, the authors described the perioperative troponin kinetics during and after lung transplantation. This single-center study had a prospective observational design, including adult patients who underwent lung transplantation in our institution from December 2016 to March 2017. The ethics committee of the Société Française d'Anesthésie et Réanimation granted its approval for the research protocol (IRB 00010254-2016-086). Troponin I was measured at selected intervals: immediately before surgery; after anesthesia induction; at first pulmonary artery clamping; upon admission into surgical intensive care unit; and 24 and 72 hours after surgery. The troponin I measurements were performed with LOCI Cardiac Troponin I assay on the Dimension Vista analyzer (Siemens Healthcare Diagnostics, Erlangen, Germany).Ten patients were enrolled. Their perioperative characteristics are detailed in Table 1. The preoperative troponin I was undetectable in all patients. Troponin I was detectable early in all patients in the intraoperative period, with a median peak value of 7.86 (4.86-8.47) ng/mL; data are median (interquartile range). The peak value has been observed postoperatively 18.5 (13-20) hours after anesthesia induction (Fig 1) and 15 (13-17) hours after pulmonary artery clamping. After the peak, troponin I decreased progressively in all patients. Beyond the second postoperative day, all patients still showed detectable troponin I. Postoperative echocardiography showed no changes in left ventricular function. No patient was diagnosed with perioperative acute coronary syndrome. All patients were treated with intraoperative norepinephrine, and 7 patients required veno-arterial extracorporeal oxygenation. The cumulated intraoperative hypotension (mean arterial pressure <65 mmHg) was <30 minutes.Table 1Patients' Perioperative Characteristics. Patients Ordered by Increasing Troponin I Peak Level.PatientAgeLT CauseLT TypeComorbiditiesI.O ECMOECMO IndicationWeaning of ECMOI.O Maximal Infusion Rate of Norepinephrine (µg/Kg/Min)I.O Cardiac EventsMicro Air -Bubbles (TEE)I.O Hemodynamic Failure (Hypotension >30 min)I.O PRBC (Units)Troponin Peak Level (ng/Ml)Troponin Peak Timing (h)*Time since anesthesia induction.Length of Surgery (h)Postoperative TTEPreop GFR (Ml/min)Postop GFR (Ml/min)151COPDBHBPNo--1.48NoYesNo321236Normal5872258Kartagener syndromeB-VAHypoxemiaYes0.3NoYesNo411.8612210NA>12022360IPFBPHT, RV dysfunction, Peripheral artery diseaseVAPHTYes0.35Nonsustained VTNoNo07.85818.54Normal6171444Kartagener syndromeBPHT, RV dysfunctionVASevere hypoxia, cardiac failureNo0.34NoYesNo47.99418.56Progressive systolic function improvement86103551IPFB-VASevere hypoxemiaYes0.83NoNoNo08.465177NA9081663IPFRPTCA on proximal LAD 4 mo agoNo--0.6NoNANo06.41204Normal>120106759IPFRHBP, DLP, obesity, PHTVAPHT, respiratoryYes0.39PMAYesNo05.80318.56Normal84>120863IPFRHBP, peripheral artery diseaseNo--0.11NoYesNo04.85614.53.5NA92106961Cystic bronchiectasisLEmphysema PHTVAPHT, Respiratory acidosisNo0.37NoYesNo02.8169.56Normal>120>1201066SilicosisL-VARespiratoryYes0.11NoYesNo22.2385Normal9098Abbreviations: B, bilateral lung transplantation; COPD, chronic obstructive pulmonary disease; DLP, dyslipidemia; ECMO, extracorporeal membrane oxygenation; HBP, high blood pressure; IPF, idiopathic pulmonary fibrosis; I.O, intraoperative; LAD, left anterior descending coronary artery; L, left lung transplantation; LVEF, left ventricle ejection fraction; LT, lung transplantation; MAP, mean arterial pressure; NA, not available; PRBC, packed red blood cells; PTCA, Percutaneous transluminal coronary angioplasty; Postop, postoperative; Postop GFR, 24 hours glomerural filtration rate (Cockroft-Gault); PMA, premature atrial contractions; Preop GFR, preoperative glomerular filtration rate; PHT, pulmonary hypertension; R, right lung transplantation; RV, right ventricle; TEE, transesophageal echocardiography; VA, veno-arterial; VT, ventricular tachycardia. Time since anesthesia induction. Open table in a new tab Troponin I kinetics after lung transplantation are similar to those described in cardiac surgery.7Alyanakian MA Deheux M Chatel D et al.Cardiac troponin I in diagnosis of perioperative myocardial infarction after cardiac surgery.J Cardiothorac Vasc Anesth. 1998; 12: 288-294Abstract Full Text PDF PubMed Scopus (92) Google Scholar, 8Ma QL Wang HJ Shi MN et al.Serum troponin I concentrations assessed 18-24 hours after coronary artery bypass grafting are significant predictors of early patient prognosis.Eur Rev Med Pharmacol Sci. 2016; 20: 4129-4135PubMed Google Scholar, 9Provenchère S Guglielminotti J Gouel-Chéron A et al.Postoperative cardiac troponin I thresholds associated with 1-year cardiac mortality after adult cardiac surgery: An Attempt to link risk stratification with management stratification in an observational study.J Cardiothorac Vasc Anesth. 2019; 33: 3320-3330Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Even if it may not be possible to isolate a single mechanism for troponin elevation, the early rise suggests direct tissue injury, especially the clamping and the section of the left atrium. These features are similar to those of uncomplicated cardiac surgery.10Weidenmann V Robinson NB Rong LQ et al.Diagnostic dilemma of perioperative myocardial infarction after coronary artery bypass grafting: A review.Int J Surg Lond Engl. 2020; 79: 76-83Crossref PubMed Scopus (6) Google Scholar Ischemia-related myocardial injury is known to induce a troponin release beginning approximately from 3 to 6 hours after the ischemic event.11Kemp M Donovan J Higham H Hooper J. Biochemical markers of myocardial injury.Br J Anaesth. 2004; 93: 63-73Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar,12Bertinchant JP Larue C Pernel I et al.Release kinetics of serum cardiac troponin I in ischemic myocardial injury.Clin Biochem. 1996; 29: 587-594Crossref PubMed Scopus (127) Google Scholar A biphasic troponin I kinetics has been described after myocardial injury,11Kemp M Donovan J Higham H Hooper J. Biochemical markers of myocardial injury.Br J Anaesth. 2004; 93: 63-73Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar with an early release of cytoplasmic troponin I followed by a persistent elevation during the first 48 hours explained by the continuing destruction of the myofilament complex.8Ma QL Wang HJ Shi MN et al.Serum troponin I concentrations assessed 18-24 hours after coronary artery bypass grafting are significant predictors of early patient prognosis.Eur Rev Med Pharmacol Sci. 2016; 20: 4129-4135PubMed Google Scholar,11Kemp M Donovan J Higham H Hooper J. Biochemical markers of myocardial injury.Br J Anaesth. 2004; 93: 63-73Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar In cardiac surgery, the most complex surgical procedures are associated with the highest troponin I peak.13Fellahi JL Hedoire F Le Manach Y et al.Determination of the threshold of cardiac troponin I associated with an adverse postoperative outcome after cardiac surgery: A comparative study between coronary artery bypass graft, valve surgery, and combined cardiac surgery.Crit Care. 2007; 11: 1-9Crossref Scopus (46) Google Scholar Our hypothesis is that the direct manipulation of the atrium is the cause of the early release of troponin I, and further release may be owing to myocardial injury.1Andrei S Kantor E Asssadi M et al.The prognostic role of early postoperative troponin I in lung transplantation—A retrospective 7-year analysis.J Cardiothorac Vasc Anesth. 2022; 36: 2328-2334Abstract Full Text Full Text PDF Scopus (1) Google Scholar An increase in troponin I is common after lung transplantation, but the kinetics of troponin I release have not been studied.1Andrei S Kantor E Asssadi M et al.The prognostic role of early postoperative troponin I in lung transplantation—A retrospective 7-year analysis.J Cardiothorac Vasc Anesth. 2022; 36: 2328-2334Abstract Full Text Full Text PDF Scopus (1) Google Scholar The lung transplant procedure includes technical specificities which may induce troponin release, including direct tissue injury due to left atrial manipulation (clamping, myotomy, sutures), handling of the heart, pulmonary artery clamping, or hemodynamic instability.1Andrei S Kantor E Asssadi M et al.The prognostic role of early postoperative troponin I in lung transplantation—A retrospective 7-year analysis.J Cardiothorac Vasc Anesth. 2022; 36: 2328-2334Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 2Lasocki S Provenchère S Bénessiano J et al.Cardiac troponin I is an independent predictor of in-hospital death after adult cardiac surgery.Anesthesiology. 2002; 97: 405-411Crossref PubMed Scopus (128) Google Scholar, 3Ekeloef S Alamili M Devereaux PJ Gögenur I. Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis.Br J Anaesth. 2016; 117: 559-568Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 4Visser HT Erasmus ME Ebels T. Cardiac luxation to facilitate off-pump bilateral lung transplantation.Ann Thorac Surg. 2007; 83: 329-330Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 5Arango Tomás E Cerezo Madueño F Salvatierra Velázquez A. Technique resource for difficult auricular anastomosis in lung transplantation.Transplant Proc. 2015; 47: 2653-2655Crossref PubMed Scopus (4) Google Scholar, 6Meyer T Binder L Hruska N Luthe H Buchwald AB. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction.J Am Coll Cardiol. 2000; 36: 1632-1636Crossref PubMed Scopus (277) Google Scholar In this pilot study, the authors described the perioperative troponin kinetics during and after lung transplantation. This single-center study had a prospective observational design, including adult patients who underwent lung transplantation in our institution from December 2016 to March 2017. The ethics committee of the Société Française d'Anesthésie et Réanimation granted its approval for the research protocol (IRB 00010254-2016-086). Troponin I was measured at selected intervals: immediately before surgery; after anesthesia induction; at first pulmonary artery clamping; upon admission into surgical intensive care unit; and 24 and 72 hours after surgery. The troponin I measurements were performed with LOCI Cardiac Troponin I assay on the Dimension Vista analyzer (Siemens Healthcare Diagnostics, Erlangen, Germany). Ten patients were enrolled. Their perioperative characteristics are detailed in Table 1. The preoperative troponin I was undetectable in all patients. Troponin I was detectable early in all patients in the intraoperative period, with a median peak value of 7.86 (4.86-8.47) ng/mL; data are median (interquartile range). The peak value has been observed postoperatively 18.5 (13-20) hours after anesthesia induction (Fig 1) and 15 (13-17) hours after pulmonary artery clamping. After the peak, troponin I decreased progressively in all patients. Beyond the second postoperative day, all patients still showed detectable troponin I. Postoperative echocardiography showed no changes in left ventricular function. No patient was diagnosed with perioperative acute coronary syndrome. All patients were treated with intraoperative norepinephrine, and 7 patients required veno-arterial extracorporeal oxygenation. The cumulated intraoperative hypotension (mean arterial pressure <65 mmHg) was <30 minutes. Abbreviations: B, bilateral lung transplantation; COPD, chronic obstructive pulmonary disease; DLP, dyslipidemia; ECMO, extracorporeal membrane oxygenation; HBP, high blood pressure; IPF, idiopathic pulmonary fibrosis; I.O, intraoperative; LAD, left anterior descending coronary artery; L, left lung transplantation; LVEF, left ventricle ejection fraction; LT, lung transplantation; MAP, mean arterial pressure; NA, not available; PRBC, packed red blood cells; PTCA, Percutaneous transluminal coronary angioplasty; Postop, postoperative; Postop GFR, 24 hours glomerural filtration rate (Cockroft-Gault); PMA, premature atrial contractions; Preop GFR, preoperative glomerular filtration rate; PHT, pulmonary hypertension; R, right lung transplantation; RV, right ventricle; TEE, transesophageal echocardiography; VA, veno-arterial; VT, ventricular tachycardia. Troponin I kinetics after lung transplantation are similar to those described in cardiac surgery.7Alyanakian MA Deheux M Chatel D et al.Cardiac troponin I in diagnosis of perioperative myocardial infarction after cardiac surgery.J Cardiothorac Vasc Anesth. 1998; 12: 288-294Abstract Full Text PDF PubMed Scopus (92) Google Scholar, 8Ma QL Wang HJ Shi MN et al.Serum troponin I concentrations assessed 18-24 hours after coronary artery bypass grafting are significant predictors of early patient prognosis.Eur Rev Med Pharmacol Sci. 2016; 20: 4129-4135PubMed Google Scholar, 9Provenchère S Guglielminotti J Gouel-Chéron A et al.Postoperative cardiac troponin I thresholds associated with 1-year cardiac mortality after adult cardiac surgery: An Attempt to link risk stratification with management stratification in an observational study.J Cardiothorac Vasc Anesth. 2019; 33: 3320-3330Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Even if it may not be possible to isolate a single mechanism for troponin elevation, the early rise suggests direct tissue injury, especially the clamping and the section of the left atrium. These features are similar to those of uncomplicated cardiac surgery.10Weidenmann V Robinson NB Rong LQ et al.Diagnostic dilemma of perioperative myocardial infarction after coronary artery bypass grafting: A review.Int J Surg Lond Engl. 2020; 79: 76-83Crossref PubMed Scopus (6) Google Scholar Ischemia-related myocardial injury is known to induce a troponin release beginning approximately from 3 to 6 hours after the ischemic event.11Kemp M Donovan J Higham H Hooper J. Biochemical markers of myocardial injury.Br J Anaesth. 2004; 93: 63-73Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar,12Bertinchant JP Larue C Pernel I et al.Release kinetics of serum cardiac troponin I in ischemic myocardial injury.Clin Biochem. 1996; 29: 587-594Crossref PubMed Scopus (127) Google Scholar A biphasic troponin I kinetics has been described after myocardial injury,11Kemp M Donovan J Higham H Hooper J. Biochemical markers of myocardial injury.Br J Anaesth. 2004; 93: 63-73Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar with an early release of cytoplasmic troponin I followed by a persistent elevation during the first 48 hours explained by the continuing destruction of the myofilament complex.8Ma QL Wang HJ Shi MN et al.Serum troponin I concentrations assessed 18-24 hours after coronary artery bypass grafting are significant predictors of early patient prognosis.Eur Rev Med Pharmacol Sci. 2016; 20: 4129-4135PubMed Google Scholar,11Kemp M Donovan J Higham H Hooper J. Biochemical markers of myocardial injury.Br J Anaesth. 2004; 93: 63-73Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar In cardiac surgery, the most complex surgical procedures are associated with the highest troponin I peak.13Fellahi JL Hedoire F Le Manach Y et al.Determination of the threshold of cardiac troponin I associated with an adverse postoperative outcome after cardiac surgery: A comparative study between coronary artery bypass graft, valve surgery, and combined cardiac surgery.Crit Care. 2007; 11: 1-9Crossref Scopus (46) Google Scholar Our hypothesis is that the direct manipulation of the atrium is the cause of the early release of troponin I, and further release may be owing to myocardial injury.1Andrei S Kantor E Asssadi M et al.The prognostic role of early postoperative troponin I in lung transplantation—A retrospective 7-year analysis.J Cardiothorac Vasc Anesth. 2022; 36: 2328-2334Abstract Full Text Full Text PDF Scopus (1) Google Scholar None.

Background: Early diagnosis and prompt management of acute mesenteric ischaemia (AMI) are key to survival but remain extremely difficult, due to vague and non-specific symptoms. Serum lactate (SL) is commonly presented as a useful biomarker for the diagnosis or prognosis of AMI. The aim of our study was test SL (1) as a diagnostic marker and (2) as a prognostic marker for AMI.Study design: This was an ancillary multicentre case-control study. Patients with AMI at intensive care unit (ICU) admission were included (AMI group) and matched to ICU patients without AMI (control group). SL was measured and compared on day 0 (D0) and day 1 (D1). Diagnosis and prognosis accuracy were assessed by receiver operating characteristic (ROC) and their area under the curve (AUC).Results: Each group consisted of 137 matched ICU patients. There was no significant difference of SL between the two groups at D0 or at D1 (p = 0.26 and p = 0.29 respectively). SL was a poor marker of AMI: at D0 and D1, AUC were respectively 0.57 [0.51; 0.63] and 0.60 [0.53; 0.67]. SL at D0 and D1 correctly predicted ICU mortality, independently of AMI (AUC D0: 0.69 [0.59; 0.79] vs. 0.74 [0.65; 0.82]; p = 0.51 and D1: 0.74 [0.64; 0.84] vs. 0.76 [0.66; 0.87]; p = 0.77, respectively, for control and AMI groups].Conclusions: SL has no specific link with AMI, both for diagnosis and prognosis. SL should not be used for the diagnosis of AMI but, despite its lack of specificity, it may help to assess severity. ?@ 2022 Socie acute accent te acute accent franc , aise d'anesthe acute accent sie et de re acute accent animation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

BACKGROUND:High-density lipoproteins (HDLs) are synthesized by the liver and display endothelioprotective properties, including anti-inflammatory, antiapoptotic, antithrombotic and antioxidant effects. In both septic and chronic liver failure patients, a low HDL cholesterol (HDL-C) concentration is associated with overmortality. Whereas sepsis-associated liver dysfunction is poorly defined, the aim of this study was to characterize the relationship between liver dysfunction, lipoprotein concentrations and mortality in septic patients in the intensive care unit (ICU).METHODS:A prospective observational study was conducted in a university hospital ICU. All consecutive patients admitted for septic shock or sepsis were included. Total cholesterol, HDL-C, low-density lipoprotein-cholesterol (LDL-C), and triglyceride levels were assessed at admission. Sepsis-associated liver dysfunction was defined as a serum bilirubin≥ 2N or aspartate aminotransferase/alanine aminotransferase concentrations ≥ 2N. Short-term and one-year prognostic outcomes were prospectively assessed.RESULTS:A total of 219 septic patients were included, and 15% of them presented with sepsis-associated liver dysfunction at admission. Low concentrations of lipoproteins were associated with mortality at Day 28 in the overall population. Sepsis-associated liver dysfunction at admission was associated with overmortality. In this subgroup, patients had a lower HDL-C concentration than patients without hepatic dysfunction (HDL-C = 0.31 [0.25, 0.55] mmol/L vs. 0.48 [0.29, 0.73] mmol/L, p = 0.0079) but there was no relationship with the outcome. Interestingly, no correlation was observed between lipoprotein concentrations and liver dysfunction markers.CONCLUSION:Sepsis-associated liver dysfunction at ICU admission is strongly associated with overmortality and is associated with a lower HDL-C concentration. However, in this subgroup of patients, HDL-C concentration had no relationship with mortality. Further exploratory studies are needed to better understand the interaction between lipoproteins and liver dysfunction during sepsis.

INTRODUCTION:Patients receiving extracorporeal membrane oxygenation (ECMO) often require renal replacement therapy (RRT). The challenge of inserting a dialysis catheter (DC) could be solved by direct connection of RRT lines on an ECMO circuit (DCRE) without published guidelines. This study aimed to describe the practice of RRT in patients on ECMO, including the DCRE as well as the perception and concerns related to this technique.METHODS:An international survey was worldwide sent via email to professionals involved in the management of ECMO. Respondents always or often performing RRT via the ECMO circuit were classified in the ECMO group, and those using a DC were classified in the DC group.RESULTS:From March 2019 to October 2019, 298 participants answered the questionnaire from 46 different countries. Only 28% were working in pediatric departments. Among the 165 participants commonly performing RRT in patients on ECMO, 100 (61%) performed mainly RRT via the ECMO circuit, and 65 (39%) performed RRT via DC. Pediatric practice and a longer experience were the only noticeable characteristics of the ECMO group. The most reported concern regarding DCRE was the risk of air embolism (n = 84, 28%), but the most encountered problem was unmanageable pressure alarms in RRT devices.CONCLUSION:The present study showed significant heterogeneity in RRT practices in patients on ECMO. The lower experience of the DC group, the high rates of concerns toward DCRE, and pressure alarm issues suggested that protocols and training may overcome reluctance and technical difficulties.

Background High-density lipoproteins (HDLs), particles characterized by their reverse cholesterol transport function, display pleiotropic properties, including anti-inflammatory and antioxidant functions. Moreover, all lipoproteins (HDLs but also low-density lipoproteins (LDLs)) neutralize lipopolysaccharides, leading to increased bacterial clearance. These two lipoproteins decrease during sepsis, and an association between low lipoprotein levels and poor outcome was reported. The goals of this study were to characterize the lipid profile of septic patients hospitalized in our intensive care unit (ICU) and to determine the relationship with the outcome. Methods A prospective observational study was conducted in a university hospital ICU. All consecutive patients admitted for septic shock or sepsis were included. Total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglyceride levels were assessed at admission (day 1), at day 3, and at ICU discharge. When available, a prehospitalization lipid profile collected prior to the patient’s hospitalization was compiled. Short-term and 1-year prognostic outcomes were prospectively assessed. Results A total of 205 patients were included. We found a decrease in HDL-C concentration between previous values and those at admission, followed by an additional decrease at day 3. At ICU discharge, the concentration was higher than that at day 3 but did not reach the concentration measured prior to hospitalization (prior HDL-C = 1.22 (1.04–1.57) mmol/l; day 1 HDL-C = 0.44 (0.29–0.70) mmol/l; day 3 HDL-C = 0.30 (0.25–0.48) mmol/l; and HDL-C at discharge = 0.65 (0.42–0.82) mmol/l). A similar trend was found for LDL-C (prior LDL-C = 2.7 (1.91–3.33) mmol/l; day 1 LDL-C = 1.0 (0.58–1.50) mmol/l; day 3 LDL-C = 1.04 (0.64–1.54) mmol/l; and LDL-C at discharge = 1.69 (1.26–2.21) mmol/l). Mixed models for repeated measures of lipoprotein concentrations showed a significant difference in HDL-C and LDL-C concentrations over time between survivors and nonsurvivors at day 28. An HDL-C concentration at admission of less than 0.4 mmol/l was associated with increased mortality at day 28 (log-rank test, p = 0.034) but not at 1 year (log-rank test, p = 0.24). An LDL-C concentration at admission of less than 0.72 mmol/l was associated with increased mortality at day 28 and at 1 year (log-rank test, p < 0.001 and p = 0.007, respectively). No link was found between prior lipid profile and mortality. Conclusions We showed no relationship between the prehospitalization lipid profile and patient outcome, but low lipoprotein levels in the ICU were strongly associated with short-term mortality.

Abstract ObjectivesPatients receiving extracorporeal membrane oxygenation (ECMO) often require renal replacement therapy (RRT). Insertion of a dialysis catheter may be challenging in these patients. Direct connection of RRT lines on an ECMO circuit (DCRE) may help circumvent this problem. However, no guidelines exist on this issue, and various types of practices may exist. This study aimed to describe the practice of RTT in patients on ECMO, including the direct connection of RTT lines on the ECMO circuit (DCRE) as well as the perception and concerns related to this technique.DesignInternational surveySetting.Worldwide diffusion via email.Subject.Professionals involved in the management of ECMOInterventions:Respondents’ characteristics were analyzed. Respondents always or often performing RRT via the ECMO circuit were classified in the ECMO group, and those using a dialysis catheter were classified in the DC group. The two groups were compared regarding their characteristics and their practice in ECMO and RRT. Participants were asked about their perceptions of DCRE and actual problems previously encountered. Measurements and Main Results:From March 2019 to October 2019, 298 participants answered the questionnaire from 46 different countries. Only 28% were working in pediatric departments. Among the 165 participants commonly performing RRT in patients on ECMO, 100 (61%) performed mainly RRT via the ECMO circuit, and 65 (39%) performed RRT via DC. Pediatric practice and a longer experience were the only noticeable characteristics of the ECMO group. The most reported fear regarding DCRE was the risk of air embolism (n=84, 28%), but the most encountered problem was unmanageable pressure alarms in RRT devices.ConclusionThe present study showed significant heterogeneity in RRT practices in patients on ECMO. The lower experience of the DC group, the high rates of fears toward DCRE, and pressure alarm issues suggested that protocols and training may overcome reluctance and technical difficulties. Further research may provide data to back specific guidelines. Take-home messageThe present study showed significant heterogeneity in RRT practices in patients on ECMO showing lower experience, fears and pressure alarm issues as barriers for direct connection of RRT lines on ECMO circuit, suggesting needs for protocols, training and specific guidelines.140-character TweetLow experience, fears and pressure alarm issues as barriers for direct connection of RRT lines on ECMO circuit, suggesting needs for protocols, training and specific guidelines.

OBJECTIVES:Postoperative cardiac troponin I concentration is predictive of worsened outcomes in cardiac surgery. Lung transplantation (LT) surgery shares common features with cardiac surgery, but postoperative troponin has yet to be investigated. The authors aimed to evaluate the association between early postoperative troponin concentration and the 1-year mortality after transplantation.DESIGN:A retrospective, observational, single-center study.SETTING:At a tertiary care, university hospital.PARTICIPANTS:Patients who underwent lung transplantation from January 2011 to December 2017 INTERVENTIONS: For each patient, preoperative, intraoperative, and postoperative data were collected, as well as the troponin I measurement at the moment of postoperative intensive care unit admission.MEASUREMENTS AND MAIN RESULTS:Two hundred twenty LT procedures were analyzed. Troponin I was elevated in all LT patients, with a median of 3.82 ng/mL-1 (2-6.42) ng/mL-1 significantly higher in non-survivors than in survivors with 5.39 (2.88-7.44) v 3.50 ng/mL (1.74-5.76), p = 0.005. In the multivariate analysis, the authors found that only the Simplified Acute Physiology Score II score (hazard ratio [HR] 1.03; 95% confidence interval [CI] [1.001; 1.05]; p = 0.007) and the need to maintain extracorporeal life support at the end of surgery (HR 2.54; 95% CI [1.36; 4.73]; p = 0.003) were independently associated with the 1-year mortality. The multiple linear regression model found that troponin levels were associated with the need for extracorporeal life support (ECLS) (p = 0.014), the amount of transfused packed red blood cells (p = 0.008), and bilateral LT (p < 0.001).CONCLUSION:Early postoperative troponin serum levels were not independently associated with 1-year mortality. Early postoperative troponin I levels were correlated to bilateral LT, the need for ECLS, and intraoperative blood transfusion.

Abstract Purpose Early diagnosis of acute mesenteric ischemia (AMI) is key to survival but remains extremely difficult, as the symptoms are vague and non-specific. Although international guidelines recommend that serum lactate is not used for AMI diagnosis, this parameter is still specifically taken into account for the diagnosis and prognosis of AMI. Our hypothesis was that serum lactate levels cannot be used to diagnose AMI or predict its outcome. Methods This was an ancillary, retrospective, observational, controlled multicenter study, approved by an Ethics Committee. Patients with AMI at adult intensive care unit (ICU) admission were included (AMI group) and matched to ICU patients without AMI (control group). Matching criteria were center, period, gender, age, and severity. Serum lactate levels were measured on day 0 (D0) and day 1 (D1) and the lactate difference (D0-D1) was calculated. Results Two hundred and seventy-four patients were included. Serum lactate levels were elevated in both groups at D0 and D1 but there was no significant difference between groups at D0 (2.7 [1.3; 5.5] vs 3.4 [1.9; 6.1] mmol/L; p = 0.284), D1 (1.8 [1.2; 3.1] vs 2.4 [1.5; 4.6] mmol/L, p = 0.547; respectively for control and AMI groups) or D0-D1. Thus, the performance of serum lactate for AMI diagnosis was poor. Concerning AMI outcome, serum lactate levels predicted ICU death in both groups at D0 and D1. Conclusions no specific association was observed between serum lactate levels and AMI. Serum lactate should not be used for the diagnosis of AMI but may help assess disease severity.

Background: Empirical antibiotherapy (EA) should target all bacteria in post-operative peritonitis (PP). Nevertheless, recent studies failed to prove a link between adequacy of EA and prognosis of PP. We sought to confirm this loss of association between adequate EA and prognosis and to analyze the evolution of patients' characteristics and antimicrobial strategies. Methods: This is was retrospective study. Patients with a positive fungal culture were excluded. The cohort was divided into two time periods. Data of survivors and non-survivors were compared within each time period. Differences between the two periods were assessed. A multivariable analysis searched for parameters associated with a higher hospital mortality rate. Results: Two hundred fifty-one patients were included, with 92 patients in the first period (P1) and 152 patients in the second period (P2). Inadequate EA was associated with a worse outcome only in P1. The multivariable analysis in the whole cohort showed that inadequate EA was associated with a higher mortality rate. When the differences noticed between the two periods were entered in the model (presence of resistant gram-positive cocci and EA comprising glycopeptides), inadequate EA was no longer associated with worse outcome. In P1, the most severe patients had more resistant bacteria, hence, had a higher rate of inadequate EA. This artifact disappeared in P2, during which broader antibiotherapies with triple EA were more often prescribed for the most severe patients. Conclusion: This study showed that the link between inadequate EA and outcome of patients with PP was at least partly artifactual in older studies.

Some guidelines advocate for managing patients with penetrating thoracic wounds in trauma centres with cardiothoracic surgery. This systematic approach is questionable. Only 15% of these patients require surgery. It is known that clinical examination fails to detect hemopneumothorax in penetrating trauma. However, no studies have evaluated the combined diagnostic performance of vital signs and the clinical evaluation of wounds. The clinical characteristics of wounds have not been investigated. We aimed to evaluate the ability of combinations of pre-hospital signs to rule out invasive chest stab trauma. This was a prospective observational study. All consecutive adult patients hospitalized in the perioperative acute care unit of a tertiary university hospital were included. Injury diagnoses were provided by exploratory surgery and imaging tests. Patients with a final diagnosis of invasive wounds (IWs) and patients with only superficial wounds were compared. Data regarding management and outcome were analysed. A total of 153 patients were included. After imaging or surgery, 58 (38%) patients were diagnosed with only superficial wounds, and 95 (62%) were diagnosed with thoracic or abdominal IWs. The false-negative rate of pre-hospital evaluations in the diagnosis of IWs was 42% [31–51]IQR25–75. In stable patients, pre-hospital data could not rule out IWs, with a negative predictive value of 58% and a positive predictive value of 70%. Twenty-nine (19%) patients required early emergent cardiothoracic surgery. Among these patients, 8 (28%) had no evidence of IWs in the pre-hospital period. Among the 59 patients without pre-hospital signs of IWs, 19 (33%) underwent at least one emergent procedure. The combination of pre-hospital vital signs, visual evaluation of wounds, and physical examination failed to rule out IWs in patients with chest stab wounds. This implies that caution is needed in triage decision-making.

PURPOSE:In postoperative peritonitis, Gram stain examination (GSE) of peritoneal fluid has been proposed as a guide for the prescription of glycopeptides and antifungal therapy in empirical antibiotherapy. No data support this approach for Gram-positive cocci. We aimed to evaluate the performance of GSE in predicting the results of the culture of peritoneal fluid.METHODS:In this retrospective single-center study, concordance between GSE and culture of peritoneal fluid was assessed for different types of microorganisms. Factors associated with concordance of the two tests were evaluated in the subpopulation of Gram-positive cocci peritonitis.RESULTS:Among the 152 episodes, the GSE was negative in 57 cases. The negative predictive value and the positive predictive value were 41% and 87% for Gram-positive cocci (GPC), 31% and 86% for Gram-negative bacilli, and 78% and 94% for fungi. GSE is not a reliable guide for the choice of empirical antibiotherapy and cannot reliably rule out the presence of GPC at culture. If we aim to achieve a high rate of adequacy, the systematic use of glycopeptide in the empirical antibiotherapy may be considered.CONCLUSION:GSE shows poor performance to predict the results of culture of peritoneal fluid in postoperative peritonitis. Avoiding covering resistant GPC cannot be based on the result of GSE.

Purpose The management of chest stab wounds necessitates to perform an efficient imaging strategy. Compared to chest X-ray, computed tomography (CT) scan has a higher sensitivity. Nevertheless, the utility of diagnosing occult injuries remains controversial. Previous studies reported very different rates of management modifications induced by CT-scan. Indeed, no study specifically addressed the issue of ruling out traumatic diaphragmatic injury (TDI) in the specific population of chest stab trauma. The aim of the study was to evaluate the rate of thoracic procedures induced or guided by the results of thoracic CT-scan in the specific population of chest stab wounds. Secondary objective was to evaluate the utility of CT-scan for the diagnosis of TDI. Methods We conducted a prospective observational study. All consecutive patients referred to the acute care unit were included. We recorded the general characteristics of patients, the localization of wounds, all imaging tests, the final injury diagnosis, and the patients’ management. We compared patients with modifications of management induced by CT-scan results to other patients. We evaluated the performance of CT-scan for the diagnosis of TDI by calculating its sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Results 153 patients were included. There were 92 patients with normal chest X-ray. 67 of them received a CT-scan. 34 (51%) patients had an abnormal CT-scan, including 19 (21%) patients with thoracic new findings, with 3 (4.5%) modification of management. There were 50 patients who had an abnormal chest X-ray. 31 of them received a CT-scan, and 31 (100%) had an abnormal CT-scan, including 19 thoracic new findings, with 11 (36%) modifications of management. The diagnostic performance of CT-scan for TDI was: sensitivity 50%; specificity 95%; NPV 72%; PPV 88%. Conclusions In chest stab trauma, CT-scans may be unnecessary outside the thoracoabdominal zone when chest X-ray is normal. In other cases, CT-scan seems to have an impact on the decision-making. In case of thoracoabdominal wounds, CT-scan helps to detect intra-abdominal injuries. The performance of CT-scan to diagnose TDI is not high enough to reliably rule out all TDI.