The medico-surgical management of cardiac tumors when there is a suspicion of malignancy is complex. Moreover, in a critically ill setting, the choice of diagnostic tools seems crucial. We present the case of a sixty-four-year-old patient with no prior medical history who was admitted to the intensive care unit with obstructive shock secondary to a right heart mass and pulmonary embolism. Clinical and biological features revealed secondary hemophagocytic lympho-histiocytosis (HLH). The patient underwent a diagnostic procedure with dual thoracoscopic and mediastinoscopy with biopsies. Following the diagnosis of primary cardiac lymphoma, the patient received sequential chemotherapy without undergoing cardiac surgery leading to initial improvement, with reductions in intracardiac obstruction and in biomarkers associated with hemophagocytic lympho-histiocytosis. When a cardiac mass is associated with extracardiac symptoms indicative of a hematological malignancy, the preferred treatment is chemotherapy, and cardiac surgery should be avoided.

Introduction La leptospirose, anthropozoonose bactérienne ubiquitaire, est plus fréquente dans les régions tropicales et la mortalité peut atteindre jusqu’à 50 % dans les formes graves. L’objectif de ce travail est de décrire l'épidémiologie et le devenir des patients atteints de leptospirose grave hospitalisés en réanimation dans les départements français d’Amérique (DFA), ainsi que les facteurs associés à la mortalité. Méthodes Il s’agit d’une étude rétrospective réalisée dans les trois réanimations de référence des DFA, du 1er janvier 2013 au 31 décembre 2023, incluant tous les patients majeurs, admis en réanimation pour une leptospirose grave. Résultats Deux cent soixante-quinze patients ont été inclus, dont 226 de sexe masculin (82 %), et d’âge médian (Q1, Q3) 56 ans (46–65). Le score IGSII médian était de 48 (35-63), le score SOFA médian était de 12 (8-15). Le délai médian entre le premier symptôme et l’admission en réanimation était de 5 jours (3-6). Les principales défaillances d'organes observées étaient : hématologique (88 %), hépatique (85 %) et rénale (82 %). Il y avait aussi une élévation des troponines (91 %). Tous les patients ont reçu des antibiotiques, principalement des céphalosporines de troisième génération (93 %). Une réaction de Jarisch-Herxheimer a été documentée dans 41,7% des cas. Le taux de mortalité était de 16% dont 1/3 dans les 48 premières heures. Les défaillances hémodynamique (p = 0,041, OR 9,13 [IC à 95 % 1,09–76,02]), respiratoire (p = 0,006, OR 8,98 [IC à 95 % 1,89–42,75]) et neurologique à l'admission en réanimation (p < 0,001, OR 4,89 [IC 95 % 2,01–11,92]), étaient indépendamment associées à la mortalité. Conclusion Les clusters cliniques de leptospirose grave dans les DFA comprennent la triade de Weil, les atteintes hémodynamique, respiratoire ou neurologique. Les facteurs indépendamment associés au décès sont les défaillances hémodynamique, respiratoire et neurologique à l'admission en réanimation.Les auteurs n’ont pas précisé leurs éventuels liens d’intérêts.

Scarce epidemiological data are available regarding necrotizing soft tissue infections (NSTIs) in tropical areas. Here we aimed to describe the clinical and biological features, and outcomes, of critically ill patients with NSTIs admitted to an intensive care unit (ICU) in a tropical setting. Furthermore, we analyzed these findings to identify distinct clinical phenotypes and explore their associations with patient outcomes. This retrospective observational study included all patients with NSTIs admitted to the ICU of the University Hospital of Guadeloupe between January 2014 and December 2023. Subgroups of patients having similar clinical profiles were identified through unsupervised clustering (factor analysis for mixed data, and hierarchical clustering on principal components). Univariate and multivariate analyses identified factors associated with 90-day mortality. During the study period, 91 NSTI patients were admitted to the ICU. The median Simplified Acute Physiology Score (SAPS) II was 45 [IQR 40–66], and the median time between hospital admission and first surgical debridement was 8 h [IQR 6–10 h]. While in the ICU, 65

Patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring mechanical ventilation suffer from a high incidence of ventilator associated pneumonia (VAP), mainly related to Enterobacterales. Data regarding extended-spectrum beta-lactamase producing Enterobacterales (ESBL-E) VAP are scarce. We aimed to investigate risk factors and outcomes of ESBL-E related VAP among critically ill coronavirus infectious disease-19 (COVID-19) patients who developed Enterobacterales related VAP. We performed an ancillary analysis of a multicenter prospective international cohort study (COVID-ICU) that included 4929 COVID-19 critically ill patients. For the present analysis, only patients with complete data regarding resistance status of the first episode of Enterobacterales related VAP (ESBL-E and/or carbapenem-resistant Enterobacterales, CRE) and outcome were included. We included 591 patients with Enterobacterales related VAP. The main causative species were Enterobacter sp (n = 224), E. coli (n = 111) and K. pneumoniae (n = 104). One hundred and fifteen patients (19

Abstract Background Aneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France mainland, by commercial airplane (6751 km flight) after being managed according to guidelines. This study describes the characteristics, management and outcomes related to these patients. Methods Retrospective observational cohort study of 148 patients admitted in intensive care unit for a suspected aSAH and transferred by airplane over a 10-year period (2010–2019). Results The median [interquartile range] age was 53 [45–64] years and 61% were female. On admission, Glasgow coma scale was 15 [13–15], World Federation of Neurological Surgeons (WFNS) grading scale was 1 [1–3] and Fisher scale was 4 [2–4]. External ventricular drainage and mechanical ventilation were performed prior to the flight respectively in 42% and 47% of patients. One-year mortality was 16% over the study period. By COX logistic regression analysis, acute hydrocephalus (hazard ratio [HR] 2.34, 95% confidence interval [CI] 0.98–5.58) prior to airplane transfer, WFNS grading scale on admission (HR 1.53, 95% CI 1.16–2.02) and age (OR 1.03, 95% 1.00–1.07) were associated with one-year mortality. Conclusion When necessary, transatlantic air transfer of patients with suspected aSAH after management according to local guidelines seems feasible and safe.

OBJECTIVES:To identify distinct phenotypes of critically ill leptospirosis patients upon ICU admission and their potential associations with outcome. DESIGN:Retrospective observational study including all patients with biologically confirmed leptospirosis admitted to the ICU between January 2014 and December 2022. Subgroups of patients with similar clinical profiles were identified by unsupervised clustering (factor analysis for mixed data and hierarchical clustering on principal components). SETTING:All patients admitted to the ICU of the University Hospital of Guadeloupe on the study period. PATIENTS:One hundred thirty critically ill patients with confirmed leptospirosis were included. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:At ICU admission, 34% of the patients had acute respiratory failure, and 26% required invasive mechanical ventilation. Shock was observed in 52% of patients, myocarditis in 41%, and neurological involvement in 20%. Unsupervised clustering identified three clusters-"Weil's Disease" (48%), "neurological leptospirosis" (20%), and "multiple organ failure" (32%)-with different ICU courses and outcomes. Myocarditis and neurological involvement were key components for cluster identification and were significantly associated with death in ICU. Other factors associated with mortality included shock, acute respiratory failure, and requiring renal replacement therapy. CONCLUSIONS AND RELEVANCE:Unsupervised analysis of critically ill patients with leptospirosis revealed three patient clusters with distinct phenotypic characteristics and clinical outcomes. These patients should be carefully screened for neurological involvement and myocarditis at ICU admission.

OBJECTIVES:Here, we report the management of a catastrophic COVID-19 Delta variant surge, which overloaded ICU capacity, using crisis standards of care (CSC) based on a multiapproach protocol.DESIGN:Retrospective observational study.SETTING:University Hospital of Guadeloupe.PATIENTS:This study retrospectively included all patients who were hospitalized for COVID-19 pneumonia between August 11, 2021, and September 10, 2021, and were eligible for ICU admission.INTERVENTION:Based on age, comorbidities, and disease severity, patients were assigned to three groups: Green (ICU admission as soon as possible), Orange (ICU admission after the admission of all patients in the Green group), and Red (no ICU admission).MEASUREMENTS AND MAIN RESULTS:Among the 328 patients eligible for ICU admission, 100 (30%) were assigned to the Green group, 116 (35%) to the Orange group, and 112 (34%) to the Red group. No patient in the Green group died while waiting for an ICU bed, whereas 14 patients (12%) in the Orange group died while waiting for an ICU bed. The 90-day mortality rates were 24%, 37%, and 78% in the Green, Orange, and Red groups, respectively. A total of 130 patients were transferred to the ICU, including 79 from the Green group, 51 from the Orange group, and none from the Red group. Multivariate analysis revealed that among patients admitted to the ICU, death was independently associated with a longer time between ICU referral and ICU admission, the Sequential Organ Failure Assessment score, and the number of comorbidities, but not with triage group.CONCLUSIONS:CSC based on a multiapproach protocol allowed admission of all patients with a good prognosis. Higher mortality was associated with late admission, rather than triage group.

To describe clinical and biological features and the outcomes of patients admitted for histoplasmosis in two intensive care units (ICU) in French Guyana and in the French West Indies (Guadeloupe). All patients admitted to these two ICUs for culture-proven histoplasmosis between January 2014 to August 2022 were included in the study. Using univariate and multivariate analysis, we assessed risk factors at ICU admission that were associated with death. Forty patients were included (65

Background Despite cefoxitin's in vitro resistance to hydrolysis by extended-spectrum beta-lactamases (ESBL), treatment of ESBL-producing Klebsiella pneumoniae (KP) infections with cefoxitin remains controversial. The aim of our study was to compare the clinical efficacy of cefoxitin as definitive antibiotic therapy for patients with ESBL-KP bacteremia in intensive care unit, versus carbapenem therapy. Methods This retrospective study included all patients with monomicrobial bacteremia hospitalized in intensive care unit between January 2013 and January 2023 at the University Hospital of Guadeloupe. The primary outcome was the 30-day clinical success defined as a composite endpoint: 30-day survival, absence of relapse and no change of antibiotic therapy. Cox regression including a propensity score (PS) and PS-based matched analysis were performed for endpoint analysis. Results A total of 110 patients with bloodstream infections were enrolled. Sixty-three patients (57%) received definitive antibiotic therapy with cefoxitin, while forty-seven (43%) were treated with carbapenems. 30-day clinical success was not significantly different between patients treated with cefoxitin (57%) and carbapenems (53%, p = 0.823). PS-adjusted and PS-matched analysis confirmed these findings. Change of definitive antibiotic therapy was more frequent in the cefoxitin group (17% vs. 0%, p = 0.002). No significant differences were observed for the other secondary endpoints. The acquisition of carbapenem-resistant Pseudomonas aeruginosa was significantly higher in patients receiving carbapenem therapy (5% vs. 23%, p = 0.007). Conclusions Our results suggest that cefoxitin as definitive antibiotic therapy could be a therapeutic option for some ESBL-KP bacteremia, sparing carbapenems and reducing the selection of carbapenem-resistant Pseudomonas aeruginosa strains.

Description of all consecutive critically ill COVID 19 patients hospitalized in ICU in University Hospital of Guadeloupe and outcome according to delay between steroid therapy initiation and mechanical ventilation onset. Very late mechanical ventilation defined as intubation after day 7 of dexamethasone therapy was associated with grim prognosis and a high mortality rate of 87%.

Background: COVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented.Methods: Patients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas- related vs. non-Pseudomonas-related VAP were also determined.Main findings: 3388 patients were analysed (63 [55-70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5-9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09-1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10-1.67]), PaO2/FiO2 ratio at intubation (HR 0.99 [0.98-0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76-0.998]), and corticosteroids (HR 1.27 [1.09- 1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16-1.55]), predominantly due to late VAP (HR 1.51 [1.26-1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar.

Introduction Guadeloupe, a French West Indies island, has been fiercely affected by two large waves of COVID.Therapeutic approach was different between the two waves in the intensive care unit (ICU). We aimed to compare the two different periods in terms of characteristics and outcomes and to evaluate risk factors associated with 60-day mortality in our overall cohort. Methods All consecutive patients with laboratory confirmed COVID-19 pneumonia and requiring oxygen support admitted in our ICU unit of University Hospital of Guadeloupe were prospectively included. Patients were treated during the first wave with a combination of Hydroxychloroquine and Azithromycin and during the second wave with dexamethasone and reinforced anticoagulation. Results In our cohort, 187 patients were included, 31 during the first one and 156 during the second. Patients were mostly male (69%) with a median age of 64years old. Patients tend to be younger during the second wave and body mass index was higher (respectively 31 vs 27kg/m2, p=0.01). Overall mortality at Day 60 was high (45%) and not different between the two waves. Among patients under mechanical ventilation risk factors associated with death in a multivariate analysis were a high number of comorbidities, a high level of SOFA score and the delay of invasive mechanical ventilation (IMV) onset after admission in ICU (OR=1.6 (95% CI 1.2 – 2.4). Conclusion Although therapeutics approach evolve, COVID-19 severe pneumonia is still associated with a high mortality rate in ICU.

Abstract Background No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock. Patients and methods This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). Results Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5–47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14–65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis. Conclusion Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1 .

To investigate whether haemodynamic intolerance to fluid removal during intermittent renal replacement therapy (RRT) in critically ill patients can be predicted by a passive leg raising (PLR) test performed before RRT. We included 39 patients where intermittent RRT with weight loss was decided. Intradialytic hypotension was defined as hypotension requiring a therapeutic intervention, as decided by the physicians in charge. Before RRT, the maximal increase in cardiac index (CI, pulse contour analysis) induced by a PLR test was recorded. RRT was then started. Ultrafiltration rate was similar in patients with and without intradialytic hypotension. Thirteen patients presented intradialytic hypotension, while 26 did not. In patients with intradialytic hypotension, it occurred 120 min [interquartile range 60–180 min] after onset of RRT. In the 26 patients without intradialytic hypotension, the PLR test induced no significant change in CI. Conversely, in patients with intradialytic hypotension, PLR significantly increased CI by 15 % [interquartile range 11–36 %]. The PLR-induced increase in CI predicted intradialytic hypotension with an area under the ROC curve of 0.89 (95 % interval confidence 0.75–0.97) (p < 0.05 from 0.50). The best diagnostic threshold was 9 %. The sensitivity was 77 % (95 % confidence interval 46–95 %), the specificity was 96 % (80–100 %), the positive predictive value was 91 % (57–100 %), and the negative predictive value was 89 % (72–98 %). Compared to patients without intolerance to RRT, CI decreased significantly faster in patients with intradialytic hypotension, with a slope difference of −0.17 L/min/m2/h. The presence of preload dependence, as assessed by a positive PLR test before starting RRT with fluid removal, predicts that RRT will induce haemodynamic intolerance.

Background Compared to many other cardiovascular diseases, there is a paucity of data on the characteristics of successfully resuscitated cardiac arrest (CA) patients with human immunodeficiency virus (HIV) infection. We investigated causes, clinical features and outcome of these patients, and assessed the specific burden of HIV on outcome. Methods Retrospective analysis of HIV-infected patients admitted to 20 French ICUs for successfully resuscitated CA (2000–2012). Characteristics and outcome of HIV-infected patients were compared to those of a large cohort of HIV-uninfected patients admitted after CA in the Cochin Hospital ICU during the same period. Results 99 patients were included (median CD4 lymphocyte count 233/mm3, viral load 43 copies/ml). When compared with the control cohort of 1701 patients, HIV-infected patients were younger, with a predominance of male, a majority of in-hospital CA (52%), and non-shockable initial rhythm (80.8%). CA was mostly related to respiratory cause (n = 36, including 23 pneumonia), cardiac cause (n = 33, including 16 acute myocardial infarction), neurologic cause (n = 8) and toxic cause (n = 5). CA was deemed directly related to HIV infection in 18 cases. Seventy-one patients died in the ICU, mostly for care withdrawal after post-anoxic encephalopathy. After propensity score matching, ICU mortality was not significantly affected by HIV infection. Similarly, HIV disease characteristics had no impact on ICU outcome. Conclusions Etiologies of CA in HIV-infected patients are miscellaneous and mostly not related to HIV infection. Outcome remains bleak but is similar to outcome of HIV-negative patients.

SummaryIn tumour lysis syndrome (TLS), metabolic alterations caused by the destruction of malignant cells manifest as laboratory abnormalities with (clinical TLS) or without (laboratory TLS) organ dysfunction. This prospective multicentre cohort study included 153 consecutive patients with malignancies at high risk for TLS (median age 54 years (interquartile range, 38–66). Underlying malignancies were acute leukaemia (58%), aggressive non‐Hodgkin lymphoma (29.5%), and Burkitt leukaemia/lymphoma (12.5%). Laboratory TLS developed in 17 (11.1%) patients and clinical TLS with acute kidney injury (AKI) in 30 (19.6%) patients. After adjustment for confounders, admission phosphates level (odds ratio [OR] per mmol/l, 5.3; 95% confidence interval [95% CI], 1.5–18.3), lactic dehydrogenase (OR per x normal, 1.1; 95%CI, 1.005–1.25), and disseminated intravascular coagulation (OR, 4.1; 95%CI, 1.4–12.3) were associated with clinical TLS; and TLS was associated with day‐90 mortality (OR, 2.45; 95%CI, 1.09–5.50; P = 0.03). In this study, TLS occurred in 30.7% of high‐risk patients. One third of all patients experienced AKI, for which TLS was an independent risk factor. TLS was associated with increased mortality, indicating a need for interventional studies aimed at decreasing early TLS‐related deaths in this setting.