ABSTRACT This study aimed to assess the viability of using the venous-to-arterial carbon dioxide partial pressure difference (P(v–a)CO2) to predict clinical worsening of septic shock, depending on central venous oxygen saturation (ScvO2). The prospective, observational, multicentric study conducted in three intensive care units (ICUs) included all patients with a septic shock episode during the first 6 h, with 122 patients assessed. Clinical worsening was defined as an increase of sequential organ failure assessment (SOFA) scores ≥1 (ΔSOFA ≥1) within 2 days. To assess the ability of P(v–a)CO2 to predict clinical worsening, univariate and multivariate analyses were performed according to ΔSOFA. A receiver-operating characteristic (ROC) analysis was used to confirm model predictions. Associations between P(v–a)CO2 and mortality were explored using correlations. Using multivariate analyses, two independent factors associated with ΔSOFA at least 1 were identified: an averaged 6-h value of lactate concentration (Lac [1–6]) (odds ratios [ORs], 2.43 [95% confidence interval, CI, 1.20–4.89]; P = 0.013) and an averaged 6-h value of P(v–a)CO2 (P(v–a)CO2 [1–6]) (OR, 1.49 [95% CI, 1.04–2.15]; P = 0.029). ROC analysis confirmed that Lac [1–6] and P(v–a)CO2 [1–6] were significantly associated with ΔSOFA at least 1, whereas ScvO2 [1–6] was not. Finally, ΔSOFA at least 1 was associated with higher 28-day (76% vs. 10%, P = 0.001) and ICU (83% vs. 12%, P = 0.001) mortality rates, which were higher in patients with P(v–a)CO2 [1–6] more than 5.8 mmHg (57% vs. 33%; P = 0.012). In conclusion, P(v–a)CO2 may help predict outcomes for septic shock patients regardless of ScvO2 values.

OBJECTIVES The aims of this study were to: 1) analyze the cannula-associated deep vein thrombosis frequency after venovenous extracorporeal membrane oxygenation using a CT scan and 2) identify the associated risk factors for cannula-associated deep vein thrombosis. DESIGN Retrospective observational analysis at a single center. SETTING Tertiary referral university teaching hospital. PATIENTS Patients under venovenous extracorporeal membrane oxygenation with a femorofemoral or femorojugular cannulation admitted for acute respiratory distress syndrome or primary graft dysfunction after pulmonary transplantation. CT scan was performed within 4 days after decannulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included 105 of 228 patients screened. Bacterial pneumonia was the main indication of venovenous extracorporeal membrane oxygenation (46.7%). CT scans were performed at a median of 2 days (1-3 d) after decannulation. Cannula-associated deep vein thrombosis was found in 75 patients (71.4%) despite it having a mean activated partial thromboplastin time ratio of 1.60 ± 0.31. Femorofemoral cannulation induced femoral cannula-associated deep vein thrombosis more frequently than femorojugular cannulation (69.2% vs 63.1%, respectively; p = 0.04). Seventeen of the 105 patients (16.2%) had a pulmonary embolism. Multivariate logistic regression analysis showed that higher the percentage of thrombocytopenia less than 100 G/L during extracorporeal membrane oxygenation period, lower the risk for developing cannula-associated deep vein thrombosis (hazard ratio, 0.98; 95% CI, 0.98-1.00; p = 0.02). CONCLUSIONS Cannula-associated deep vein thrombosis after venovenous extracorporeal membrane oxygenation is a frequent complication. This plead for a systematic vascular axis imaging after venovenous extracorporeal membrane oxygenation. Thrombocytopenia is associated with a reduction in the occurrence of thrombotic events.

This single-center case series investigated the effect of almitrine infusion on Pa o 2 /fraction of inspired oxygen (F io 2 ) in 25 patients on veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. A positive trial was defined as an increase of Pa o 2 /F io 2 ratio ≥20%. Thirty-two trials were performed. Twenty (62.5%, 95% confidence interval, 37.5%–75%) trials in 18 patients were positive, with a median Pa o 2 /F io 2 ratio increase of 35% (25%–43%). A focal acute respiratory distress syndrome and inhaled nitric oxide therapy were more frequent in patients with a positive response to almitrine. We observed no complications of almitrine use.

Acute respiratory distress syndrome (ARDS) commonly affects intensive care unit patients and is associated with high mortality. In addition to etiologic treatment and protective ventilation, non-ventilatory therapies represent a significant part of ARDS care. Pharmacological treatments, extra corporeal devices and prone positioning are commonly grouped under this term. Studies have evaluated the individual effects of some of these non-ventilatory therapies in large randomized controlled trials. Recent advances concerning the beneficial use of neuromuscular blocking agents and prone positioning deserve attention. Conversely, the use of inhaled nitric oxide and almitrine remains to be specified. The debate concerning the role of corticosteroids could be renewed considering the emergence of new biomarkers. Finally, the use of extracorporeal membrane oxygenation and extra-corporeal CO2 removal remain under question. The aim of this review is to summarize the latest data concerning the mainly used non-ventilatory therapies and to integrate them into a global strategy of ARDS patient care.

To investigate whether neuromuscular blocking agents (NMBA) exert beneficial effects in acute respiratory distress syndrome (ARDS) by reason of their action on respiratory mechanics, particularly transpulmonary pressures (P L).

Nosocomial infections occurring during extracorporeal membrane oxygenation (ECMO) support have already been reported, but few studied infections directly related to ECMO devices. This study aims to evaluate the rate of both colonisations and infections related to ECMO devices at the time of ECMO removal.

We report the first case of organ-transmitted varicella reinfection in a lung transplant patient who had previously contracted primary varicella during childhood. CASE REPORT A 62-year-old woman with diffuse bronchiectasis was admitted to our Intensive care unit after lung transplantation complicated by grade 3 primary graft dysfunction. The donor was a 31-year-old man deceased from a stroke due to an intracranial arteriovenous malformation. The patient was varicella zoster virus (VZV) seropositive but had never developed herpes zoster. Anti-infectious treatment with imipeneme-cilastatine, colimycine, and voriconazole was started during surgery based on previous microbiological information (cured aspergillosis and current colonization with multiple-drug–resistant Achromobacter xylosoxidans). Because both the patient and donor were seronegative for cytomegalovirus and herpes simplex virus, the patient did not receive antiviral prophylaxis per our protocol. She had received induction therapy with rabbit antithymocyte globulin and an immunosuppressive regimen with cyclosporine and methylprednisone. Due to the persistent respiratory failure, a bronchoalveolar lavage with extensive microbiological investigations was performed on day 3. On day 6, sudden septic shock without fever or examination signs occurred. Central hypovolemia and normal cardiac function were assessed by echocardiography. Worsening of bilateral opacities visible on chest X-ray was the only substantial finding. Empirical ganciclovir treatment was started subsequently. On day 7, a screening for VZV infection conducted on day 6 by quantitative blood polymerase chain reaction (PCR) analysis was positive with a viral load of 4.2 × 104 copies/mL. Although the treatment drug was changed to acyclovir the patient developed a multiorgan failure and died on day 9. She never developed skin eruption. The PCR results from the bronchoalveolar lavage and the postmortem lung biopsies were positive for VZV with viral loads of respectively 10.4 × 107 copies/mL and 9.7 × 106 VZV copies/millions of cells. Histologic analyses were consistent with VZV infection (Figure 1) without cell rejection. Anti-HLA antibodies were undetectable on day 5.FIGURE 1: The lung biopsy histological examination was highly suggestive of VZV infection (confirmed by PCR done on the lung biopsy) with few cells presenting intranuclear inclusion bodies. There was an associated diffuse acute interstitial inflammatory infiltrate with patterns of diffuse alveolar damage with hyaline membranes (acute respiratory distress syndrome). There were no signs of acute rejection (hematoxylin-eosin saffron staining, ×20). Image courtesy of Mr. Brandone.Despite the absence of symptoms and the immunoglobulin G and M seronegativity of the donor, we performed VZV-specific PCR analysis of donor lung biopsies and blood samples. Both were positive. Neither the patient nor the donor had received a VZV vaccine. We concluded that death occurred consecutive to VZV reinfection. DISCUSSION To our knowledge, this is the first description of an organ-transmitted VZV infection to a VZV seropositive recipient. The first case of organ-transmitted varicella was reported after pediatric cardiac transplantation, but the receiver was VZV seronegative, and the donor had been recently treated for primary varicella.1 Previous cases of clinical reinfection have been rarely reported in immunocompromised patients.2 As suggested in an experimental model,3 exposure to a concentrated inoculum from a viremic donor along with severe T-cell depletion may have favored a rapid and severe dissemination. It may also explain the unusual presentation with septic shock as the sole manifestation of infection. The fatal evolution is consistent with the high mortality reported in cases of disseminated VZV infection without skin eruption in the context of lung transplantation.4 As such presentation could hardly have been prevented, it highlights the susceptibility of solid organ recipients to herpes viruses and indicates the need for broad suspicion, screening and early empiric treatment.

Neuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO2/FiO2 ratio less than 120 with a PEEP ≥5 cm H2O were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters.