Fulminant myocarditis (FM) is a severe condition primarily triggered by viruses. Anti-RNA polymerase III autoantibodies (RNApol3) which are typically found in patients with severe systemic sclerosis, have been reported in patients with influenza-related FM. Our objective is to provide additional insight into RNApol3-associated FM. We retrospectively included all patients admitted to our institution between January 2013 and June 2023 with acute myocarditis and positive serum RNApol3. We compared their characteristics, etiologies, and outcomes with those of a cohort of RNApol3 negative acute myocarditis. Twenty-nine RNApol3-positive patients, comprising 83

OJECTIVE:We aim to describe a large, multicenter cohort of patients with bloodstream infection (BSI) acquired during extracorporeal membrane oxygenation (ECMO) support. METHODS:We conducted a retrospective observational study in 12 Europeans ICUs. Only patients who developed a BSI of unknown source during ECMO support were included in the present analysis. Primary aim was to describe BSI epidemiology in patients with ECMO support. Secondary objectives were to describe antimicrobial susceptibility of incriminated micro-organisms. RESULTS:One hundred and eighty-two patients were included. Main reason for ECMO support was ARDS, followed by cardiogenic shock and post-cardiotomy. Half of the patients (51.9%) received early antimicrobial therapy. Main incriminated microorganisms were Enterococcus sp. (37.4%), Enterobacterales (26.9%), coagulase negative Staphylococci (15.9%) and Gram negative bacilli (11.5%). Multi drug resistant organisms (MDRO) were incriminated in 26 (14.3%) BSI and were mainly extended spectrum producing-Enterobacterales (17/26). Antimicrobial therapy was considered as appropriate in 130 patients (71.4%). Patients who received inappropriate antimicrobial therapy were more frequently infected with MDRO. Only 59 (32.4%) of cases were susceptible to 3rd generation cephalosporin while association of piperacillin/tazobactam with vancomycin was considered appropriate in 155 cases (85.2%) as compared with 168 cases (92.3%) for carbapenems combined with vancomycin. CONCLUSION:Enterococcus sp. was incriminated in about a third of BSI among patients with ECMO support. High appropriateness would only be obtained with piperacilline/tazobactam or carbapenems in association with vancomycin while 3rd generation cephalosporin would have failed in the majority of BSI cases. CLINICAL TRIAL NUMBER:Not applicable.

OBJECTIVE:Only few data regarding epidemiology and management of ECMO cannula-related infections (ECMO-CRIs) exist. The aim of our study was to describe their epidemiology and prognosis, and to evaluate factors associated with outcome. METHODS:We performed a multicenter retrospective study in 12 European ICUs, including patients with ECMO-CRI, defined as a clinical suspicion plus a positive bacterial sample of ECMO-cannulation site. Primary objective was to describe ECMO-CRI characteristics and outcomes. Secondary objectives were to evaluate the rates of infection recurrence, their risk factors, and to evaluate the impact of antimicrobial treatment duration on outcome. RESULTS:During the study period, 109 patients with ECMO-CRI (78 having concomitant positive blood culture with the same pathogen) were included. Pathogens responsible for infections were predominantly Enterobacteriaceae, coagulase-negative Staphylococcus and Enterococcus spp., and 42% of episodes were polymicrobial. Rates of infection recurrence was 13% and ICU-mortality rate was 51%. Risk factors for death were concomitant bloodstream infection with same pathogen and septic shock Patients with antibiotic course ≤ 8 days had similar infection recurrence rate and outcomes (including mortality) than patients with prolonged (> 8 days) antibiotic course. CONCLUSION:ECMO-CRIs are frequently associated with BSI and frequently polymicrobial. Duration of antimicrobial treatment for ECMO-CRI ≤ 8 days does not seem to be associated with an increased risk of recurrence or death, as compared to longer treatment.

BACKGROUND:Intensive care units (ICU) are characterized by high medical assistance costs and great complexity. Recommendations to determine the needs of medical staff are scarce, generating appreciable variability. The French Intensive Care Society (FICS) and the French National Council of Intensive Care Medicine (CNP MIR, Conseil National Professionel de Médecine Intensive Réanimation) have established a technical committee of experts, the purposes of which were to draft recommendations regarding staffing needs in ICUs and to propose optimal organisation of work hours, a key objective being improved workplace quality of life. RESULTS:Literature analysis was conducted according to the GRADE methodology (Grade of Recommendation Assessment, Development and Evaluation). The synthesis work of the experts according to the GRADE method led to the development of 22 recommendations in 6 field. The experts issued a strong recommendation associated with a high level of evidence which is that work organization be given priority during periods of permanent care, with a maximum 16 h of consecutive work permitted. For 21 other recommendations, the level of evidence did not allow GRADE classification, and led to the formulation of expert opinions. All recommendations and expert opinions were validated (strong agreement). CONCLUSION:The work in the intensive care unit and in the intermediate intensive care unit is multifaceted, both clinical and non-clinical, and must include at least the following continuity and quality for patient safety. This document provides a detailed framework to propose an optimal medical staff.

OBJECTIVES:. Neurologic outcomes of patients under venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be worsened by secondary insults of systemic origin. We aimed to assess whether sepsis, commonly observed during ECMO support, is associated with brain injury and outcomes. DESIGN:. Single-center cohort study of the “exposed-non-exposed” type on consecutive adult patients treated by VA-ECMO. SETTING:. Medical ICU of a university hospital, France, 2013–2020. PATIENTS:. Patients with sepsis at the time of VA-ECMO cannulation (“sepsis” group) were compared with patients without sepsis (“no sepsis” group). The primary outcome measure was poor functional outcome at 90 days, defined by a score greater than or equal to 4 on the modified Rankin scale (mRS), indicating severe disability or death. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. A total of 196 patients were included (“sepsis,” n = 128; “no sepsis,” n = 68), of whom 87 (44.4%) had presented cardiac arrest before VA-ECMO cannulation. A poor functional outcome (mRS ≥ 4) was observed in 99 of 128 patients (77.3%) of the “sepsis” group and 46 of 68 patients (67.6%) of the “no sepsis” group (adjusted logistic regression odds ratio (OR) 1.21, 95% CI, 0.58–2.47; inverse probability of treatment weighting (IPTW) OR 1.24; 95% CI, 0.79–1.95). Subsequent analyses performed according to pre-ECMO cardiac arrest status suggested that sepsis was independently associated with poorer functional outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest (adjusted logistic regression OR 3.44; 95% CI, 1.06–11.40; IPTW OR 3.52; 95% CI, 1.68–7.73), whereas no such association was observed in patients without pre-ECMO cardiac arrest (adjusted logistic regression OR 0.69; 95% CI, 0.27–1.69; IPTW OR 0.76; 95% CI, 0.42–1.35). Compared with the “no sepsis” group, “sepsis” patients presented a significant increase in S100 calcium-binding protein beta concentrations at day 1 (0.94 μg/L vs. 0.52 μg/L, p = 0.03), and more frequent EEG alterations (i.e., severe slowing, discontinuous background, and a lower prevalence of sleep patterns), suggesting brain injury. CONCLUSION:. We observed a detrimental role of sepsis on neurologic outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest, but not in other patients.

Le groupe FEMMIR s’est formé en 2019 pour se pencher sur les problématiques de genre en réanimation : égalité femmes-hommes, discrimination et violences ressenties par les femmes médecin. La première étape de son travail a été d’établir un état des lieux : le nombre de femmes et d’hommes est relativement semblable parmi les praticien-nes de médecine intensive et réanimation, mais la proportion de femmes diminue aux postes-clés (chef-fes de service, professeur-es, intervenant-es en congrès, expert-es intervenant dans les médias) ; de nombreuses femmes ont déjà vécu par ailleurs des discriminations ou des comportements sexistes voire du harcèlement ou des agressions sexuelles. La deuxième étape a été d’entreprendre des actions pour promouvoir l’égalité des genres et la sensibilisation aux discriminations : engagement pour la parité au sein des commissions, des congrès et des journaux, création d’une liste d’expertes, publication d’articles de recherche à propos du genre chez les patient-es ou les praticien-nes, mis en place d’un enseignement auprès des internes et de formations aux professionnel-les de santé, communication sur les réseaux sociaux et création de réseaux inter-spécialités et internationaux. Le groupe va poursuivre et consolider son action sur ces sujets dans les années à venir.

Despite systemic thrombolysis, a few patients with high-risk pulmonary embolism (PE) remain hemodynamically unstable. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a considerable lifesaving therapy but systemic thrombolysis before cannulation could carry a high risk of hemorrhage and alter the prognosis. Between June 2012 and June 2023, we retrospectively analyzed from three intensive care units in Sorbonne University, ECMO-related complications and 90-day mortality for high-risk PE patients who received ECMO without previous systemic thrombolysis compared to those cannulated after systemic thrombolysis failure. Hospital discharge survivors were assessed for long-term health-related quality of life and echocardiographic evaluations. 72 high-risk PE patients [median age 48 (37–61) years, Simplified Acute Physiology Score II (SAPS II) 74 (60–85)] were placed on VA-ECMO for 5 (5–7) days. 31 (43

Cardiogenic shock (CS) is characterized by low cardiac output and sustained tissue hypoperfusion that may result in end-organ dysfunction and death. CS is associated with high short-term mortality, and its management remains challenging despite recent advances in therapeutic options. Timely diagnosis and multidisciplinary team-based management have demonstrated favourable effects on outcomes. We aimed to review evidence-based practices for managing patients with ischemic and non-ischemic CS, detailing the multi-organ supports needed in this critically ill patient population.

A recent randomized controlled trial of extracorporeal CO2 removal (ECCO2R) in chronic obstructive pulmonary disease (COPD) patients reported bleeding as a major concern.1 While different mechanisms, such as thrombocytopenia, coagulation factor consumption, acquired von Willebrand disease,2 severe endothelial dysfunction,3 and anticoagulation-related side effects, could explain bleeding during implantation, preimplantation hemostatic status has not been fully explored. We investigated the association between platelet activation before ECCO2R initiation and the occurrence of severe bleeding during ECCO2R therapy in 16 COPD patients. We found that severe bleeding during ECCO2R was associated with a higher expression of CD40 Ligand (sCD40L) before ECCO2R. Extracorporeal CO2 removal, which is based on old concepts but with continuous technical improvements,4 has the potential to shift our current approaches to treating both acute hypercapnic failure (mainly acute exacerbation [AE] of COPD [AE-COPD] patients) and acute hypoxemic respiratory failure (mainly acute respiratory distress syndrome patients). However, hemorrhagic and thrombotic side effects have been reported, along with hemolysis.4–7 Platelet activation or hyper-reactivity have been reported in stable COPD and AE-COPD patients.8 Therefore, we searched for associations between corresponding biologic status and further occurrences of hemorrhagic complications during ECCO2R. We explored these points using a formalized ECCO2R register (NCT02965079) combined with a study project (Hector: Hemostasis and ECCO2R).3 Methods This study included consecutive AE-COPD patients with an ECCO2R decision therapy in a single center. We recorded severe hemorrhagic events (types 3–5 of the Bleeding Academic Research Consortium standardized classification)9 and analyzed classic hemostasis parameters before the implantation of ECCO2R devices and during ECCO2R courses. Two medical devices were used: the Hemolung device, ALung, Pittsburgh, with 15.5 Fr veno–venous catheters (either femoral or right internal jugular) or the iLA Activve device, Xenios/Novalung, Heilbronn, Germany, with veno–venous catheters, either femoral (24 Fr) or right internal jugular (18 Fr). All patients were treated with unfractionated heparin with an aXa goal of 0.3 to 0.6 IU/ml. We quantified plasma platelet activation markers—sCD40L and soluble P-selectin (sP-sel)—and endothelial activation markers—E-selectin (sE-sel) and Angiopoietin-2 (Ang-2). For the descriptive analysis, data are expressed as median (interquartile range) for continuous variables and frequencies and percentages for categorical variables. To compare continuous data, we used the Mann-Whitney U test, while Fisher's exact test was used for categorical variables. All statistical analyses were conducted as two-sided tests, with a significance level of p < 0.05. We used R Studio software, including R version 4.3.1. Results Sixteen acute AE-COPD patients were included. Their main demographics and clinic-biologic characteristics are described in Table 1 and were, in part, reported in a previously published study focusing on the course of endothelial dysfunction during ECCO2R.3 Eight patients were treated with the Hemolung device, and eight patients were treated with the iLA Activve device. A severe hemorrhagic event was observed in five patients. The characteristics of these events are reported in Table 2. The duration of ECCO2R was 5 [4, 8] days for 11 patients without severe hemorrhagic complication and 8 [8, 8] days for five patients with severe hemorrhagic complication (p < 0.001). Patients with severe bleeding during support displayed no differences in leukocytes, hemoglobin, and platelets counts before ECCO2R implantation (respectively, with a p value of 0.336, 0.212, and 0.193). No difference in daily unfractionated heparin (UFH), daily aXa, or daily platelet count during ECCO2R therapy was observed.3 Table 1. - Main Demographics, Clinical and Biologic Characteristics at Baseline (Before ECCO2R Initiation) in 16 AE-COPD Patients, Separated Between 11 Patients Without or Five Patients With Severe Hemorrhagic Complication During ECCO2R No Severe Hemorrhage Severe Hemorrhage p Demography and clinical course n 11 5 NA Age (years) 67 [60, 70] 64 [63, 76] 0.530 Male/female, n/ n 5/6 2/3 1 SAPS2 33 [27, 47] 40 [32, 45] 0.649 Charlson score 3 [1, 5] 4 [2, 4] 0.954 BMI (kg/m2) 27 [24, 39] 25 [24, 25] 0.533 Platelet aggregation inhibitor (n) 1 (clopidogrel–aspirin) 0 1 ECCO2R duration (days) 5 [4, 8] 8 [8, 8] 0.038 ICU survival, n (%) 9 (82%) 3 (60%) 0.755 ICU length of stay (days) 21 [16, 35] 15 [15, 16] 0.172 Biologic values before ECCO2R implantation PaO2 (mm Hg) 67 [62, 76] 69 [66, 76] 0.734 PaCO2 (mm Hg) 70 [67, 73] 67 [62, 70] 0.280 pH 7.27 [7.22, 7.32] 7.30 [7.28, 7.30] 0.776 Leucocytes (G/L) 13 [8.45, 16.80] 10.20 [9.70, 11.40] 0.336 Hemoglobin (g/100 ml) 12.50 [10.65, 13.25] 10.80 [7.30, 11.10] 0.212 Platelets (G/L) 261 [191, 359] 177 [154, 247] 0.193 Fibrinogen (g/L) 4.9 [4.4, 6.2] 5.3 [5.0, 5.7] 0.955 INR 1.30 [1.05, 1.35] 1.20 [1.10, 1.20] 0.455 aPTT ratio 0.93 [0.91, 1.08] 1.07 [0.90, 1.20] 0.621 D-dimer (ng/ml) 929 [668, 1625] 1,654 [755, 3,319] 0.462 sCD40L (ng/ml) 1,420 [1,196, 1,510] 2,624 [2,574, 2,673] 0.033 sP-sel (ng/ml) 28,311 [25,124, 32,081] 61,931 [49,531, 74,330] 0.059 sE-sel (ng/ml) 35,299 [19,268, 48,207] 63,507 [45,260, 81,753] 0.475 Ang-2 (pg/ml) 7,658 [5,456, 12,505] 15,969 [11,406, 20,532] 0.637 Ang-2, angiopoietin-2; aPTT, activated partial thromboplastin clotting time; BMI, body mass index; ICU, intensive care unit; INR, international normalized ratio; SAPS, simplified acute physiology score; sCD40L, CD40 ligand; sE-sel; E-selectin; sP-sel, soluble P-selectin. Table 2. - Characteristics of the Severe Bleeding Events Observed in Five Patients Patient # 1 # 2 # 3 # 4 # 5 Timing of bleeding (ECCO2R days) D7 D1 D7 D1 D6 ECCO2R cessation No No Yes No No BARC classification 3a 3b 3b 3a 3b Site of bleeding ENT ECCO2R catheter insertion* Retroperitoneal ECCO2R catheter insertion* Gastrointestinal Number of packed red blood cells 0 2 3 2 2 ECCO2R device Hemolung Hemolung iLA Activve iLA Activve iLA Activve Catheter size (Fr) 15.5 15.5 18 24 18 Access point Right internal jugular Right internal jugular Right internal jugular Right femoral Right internal jugular No patient suffered from more than a severe bleeding event.*No difficulties during catheter insertion.BARC, Bleeding Academic Research Consortium; ECCO2R, extracorporeal CO2 removal. Regarding hemostasis, patients with severe bleeding during support had similar levels of D-dimer and fibrinogen before ECCO2R implantation (respectively, with a p value of 0.462 and 0.955). No differences in prothrombin time (PT) and activated partial thromboplastin clotting time (aPTT) ratios were observed (Table 1). We then analyzed plasma levels of platelet and endothelial activation markers. In patients with further bleeding during support, sCD40L was significantly increased (p = 0.033), while the difference in sP-sel values did not reach statistical significance (p = 0.059). Endothelial activation markers sE-sel and Ang-2 levels were comparable between groups before ECCO2R implantation. Since blood acidification has been recently described to modify platelet activation during ECCO2R,10 we compared arterial blood gas analysis before ECCO2R implantation in patients with or without bleeding during support and did not find any differences for pH and arterial partial pressure of carbon dioxide (PaCO2). Discussion Overall, our results obtained in a homogeneous group of very severe AE-COPD patients suggest that increased platelet activation before ECCO2R implantation may be one mechanism that contributes to bleeding during support, besides other factors such as the type of device, the blood flow rate, the types of vascular access, and the anticoagulation regimen. Platelet activation was more pronounced in the subgroup of patients further suffering from severe bleeding during ECCO2R. We hypothesize that platelet activation observed before ECCO2R implantation could impair their ability to aggregate. Platelets are a major constituent of almost all thrombi, independent of their location and composition in red blood cells and fibrin, suggesting that they are actors impossible to circumvent in thrombus formation during extracorporeal support. Accordingly, monitoring platelet parameters before ECCO2R but also ECMO implantation could be of value for predicting whether a patient may bleed during support. However, positive validation studies would be a necessary step before implementing such biologic monitoring in the clinical practice. Additionally, investigating bleeding in patients treated with low-flow rotational blood pumps ECCO2R devices seems mandatory, considering their major differences with centrifugal pumps ECCO2R devices. Such investigations should include the evaluation of the influence of platelet activation on bleeding.

BACKGROUND:Cardiac arrest remains a global health issue with limited data on long-term outcomes, particularly regarding recurrent cardiovascular events in patients surviving out-of-hospital cardiac arrest. (OHCA). We aimed to describe the long-term occurrence of major cardiac event defined by hospital admission for cardiovascular events or death in OHCA hospital survivors, whichever came first. Our secondary objective were to assess separately occurrence of hospital admission and death, and to identify the factors associated with major event occurrence. We hypothesized that patients surviving an OHCA has a protracted increased risk of cardiovascular events, due to both presence of the baseline conditions that lead to OHCA, and to the cardiovascular consequences of OHCA induced acute ischemia-reperfusion. METHODS:Consecutive OHCA patients from three hospitals of Sudden Death Expertise Center (SDEC) Registry, discharged alive from 2011 to 2015 were included. Long-term follow-up data were obtained using national inter-regime health insurance information system (SNIIRAM) database and the national French death registry. The primary endpoint was occurrence of a major event defined by hospital admission for cardiovascular events and death, whichever came first during the follow-up. The starting point of the time-to-event analysis was the date of hospital discharge. The follow-up was censored on the date of the first event. For patients without event, follow-up was censored on the date of December, 29th, 2016. RESULTS:A total of 306 patients (mean age 57; 77% male) were analyzed and followed over a median follow-up of 3 years for hospital admission for cardiovascular event and 6 years for survival. During this period, 38% patients presented a major event. Hospital admission for cardiovascular events mostly occurred during the first year after the OHCA whereas death occurred more linearly during the all period. A previous history of chronic heart failure and coronary artery disease were independently associated with the occurrence of major event (HR 1.75, 95%CI[1.06-2.88] and HR 1.70, 95%CI[1.11-2.61], respectively), whereas post-resuscitation myocardial dysfunction, cardiogenic shock and cardiologic cause of cardiac arrest did not. CONCLUSION:Survivors from OHCA must to be considered at high risk of cardiovascular event occurrence whatever the etiology, mainly during the first year following the cardiac arrest and should require closed monitoring.

L’assistance circulatoire, concept né des observations des physiologistes du XVIIIe siècle, a permis au mi-temps XXe siècle la naissance de la chirurgie cardiaque sous circulation extra-corporelle telle que nous la connaissons aujourd’hui. Ces techniques ont ensuite été adaptées pour le traitement plus prolongé des défaillances respiratoires et cardiaques réfractaires en réanimation. Transformées en machines de longue durée, elles accompagnent désormais les malades en ambulatoire vers des projets de transplantation cardiaque et parfois comme support définitif. Progressivement les machines se sont perfectionnées, permettant une utilisation plus prolongée et réduisant les complications hémorragiques, hémolytiques et infectieuses. La circulation extracorporelle avec oxygénateur à membrane, ou extracorporeal membrane oxygenation (ECMO) en littérature anglo-saxonne est aujourd’hui la plus utilisée des assistances circulatoires de courte durée. De nouvelles indications apparaissent régulièrement, permettant la prise en charge de patients auparavant considérés comme incurables. Il reste encore à préciser la place de ces traitements dans les algorithmes de traitement des défaillances cardiorespiratoires aigues et chroniques.

Postcardiac arrest shock (PCAS) is defined by hemodynamic instability occurring in the first hours after cardiac arrest (CA) and is a major cause of mortality among patients hospitalized after CA. It includes vasoplegia and myocardial dysfunction. This postcardiac arrest myocardial dysfunction is supposed to recover within the 3 days. However, there are many unknowns regarding its definition, its prognosis value and its management. In this review dedicated to emergency physicians, we choose to address tips and pitfalls they should know regarding this prevalent syndrome.

BACKGROUND:In-hospital cardiac arrest(IHCA) has received little attention compared with out-of-hospital cardiac arrest. AIM:To address the paucity of data on IHCA patients, we examined key features, variations in mortality and predictors of death among patients admitted in French intensive care units(ICUs) from 1997 to 2015. METHODS:Using the database of the Collège des Utilisateurs de Bases de données en Réanimation(CUB-Réa) that prospectively collects data from ICUs in the greater Paris area, we determined temporal trends in the incidence of IHCA, patients' outcomes, crude and Simplified Acute Physiology Score(SAPS)-II Standardized mortality and predictors of in-ICU mortality. RESULTS:Of the 376,325 ICU admissions, 15,324(4.08%) had IHCA, with incidence increasing from 2.78% to 3.83%(p < 0.001). Over time, the patient age increased by 0.7 years(p = 0.04) and SAPS-II increased by 2.3%(p < 0.001). Crude in-ICU mortality decreased from 78% to 62.5% over the past 18 years(p < 0.001). The SAPS-II-standardized mortality also decreased over time from 78.4% to 68.3%(p < 0.001) representing a 10.1% relative decrease from 1997 to 2015. In multivariate analysis, admission in a more recent time-period was an independent correlate of decreased mortality(OR 0.40, 95%CI 0.35-0.46). CONCLUSION:Occurrence of IHCA increased over time but remains an uncommon reason for being admitted to ICU. From 1997 to 2015, we observed a change in patient profile, with older and more critically ill patients, despite which in-ICU mortality has substantially decreased in IHCA patients, likely resulting from a global improvement in the process of care and more widespread implementation of rapid response teams.

Backgound: Whether epinephrine or norepinephrine is preferable as the continuous intravenous vasopressor used to treat postresuscitation shock is unclear. Objectives: To compare outcomes of patients with postresuscitation shock after out-of-hospital cardiac arrest according to whether the continuous intravenous vasopressor used was epinephrine or norepinephrine. Methods: We conducted an observational multicenter study of consecutive patients managed in 2011-2018 for postresuscitation shock. The primary outcome was all-cause hospital mortality, and secondary outcomes were cardiovascular hospital mortality and unfavorable neurological outcome (Cerebral Performance Category 3 to 5). A multivariate regression analysis and a propensity score analysis were performed, as well as several sensitivity analyses. Results: Of the 766 patients included in five hospitals, 285 (37%) received epinephrine and 481 (63%) norepinephrine. All-cause hospital mortality was significantly higher in the epinephrine group (OR 2.6; 95%CI, 1.4-4.7; P =0.002). Cardiovascular hospital mortality was also higher with epinephrine (aOR 5.5; 95%CI 3.0-10.3; P <0.001), as was the proportion of patients with CPC of 3 to 5 at hospital discharge. Sensitivity analyses produced consistent results. The analysis involving adjustment on a propensity score to control for confounders showed similar findings (aOR 2.1; 95%CI 1.1-4.0; P =0.02). Conclusions: Among patients with postresuscitation shock after out-of-hospital cardiac arrest, use of epinephrine was associated with higher all-cause and cardiovascular-specific mortality, compared with norepinephrine infusion. A randomized controlled trial comparing the two vasopressors in this population is warranted.

Ascitic fluid infection (AFI) is a life-threatening complication of cirrhosis. We aimed to identify early indicators of secondary peritonitis (SP), which requires emergency surgery, and to describe the outcomes of SP and spontaneous bacterial/fungal peritonitis (SBFP). Adults with cirrhosis and AFI admitted to 16 university or university-affiliated ICUs in France between 2002 and 2017 were studied retrospectively. Cases were identified by searching the hospital databases for relevant ICD-10 codes and hospital charts for AFI. Logistic multivariate regression was performed to identify factors associated with SP. Secondary outcomes were short- and long-term mortality and survivors’ functional outcomes. Of 178 included patients (137 men and 41 women; mean age, 58 ± 11 years), 21 (11.8%) had SP, confirmed by surgery in 16 cases and by abdominal computed tomography in 5 cases. Time to diagnosis exceeded 24 h in 7/21 patients with SP. By multivariate analysis, factors independently associated with SP were ascitic leukocyte count > 10,000/mm 3 (OR 3.70; 95%CI 1.38–9.85; P = 0.009) and absence of laboratory signs of decompensated cirrhosis (OR 4.53; 95%CI 1.30–15.68; P = 0.017). The 1-year mortality rates in patients with SBFP and SP were 81.0% and 77.5%, respectively (Log-rank test, P = 0.92). Patients with SP vs. SBFP had no differences in 1-year functional outcomes. This multicenter retrospective study identified two indicators of SP as opposed to SBFP in patients with cirrhosis. Using these indicators may help to provide early surgical treatment.

Aims Few studies describe recent changes in the prevalence, management, and outcomes of cardiogenic shock (CS) patients complicating acute myocardial infarction (AMI) in the era of widespread use of invasive strategies. The aim of the present study was to analyse trends observed in CS complicating AMI over the past 10 years, focusing on the timing of CS occurrence (i.e. primary CS, CS on admission vs. secondary CS, CS developed subsequently during hospitalization). Methods and results Three nationwide French registries conducted and designed to evaluate AMI management and outcomes in 'real-life' practice included consecutive AMI patients (n = 9951) admitted to intensive cardiovascular care units (ICCUs) over a 1-month period, 5 years apart. The prevalence of CS complicating AMI decreased from 2005 to 2015: 5.9%, mean age 74.1 +/- 12.7 in 2005; 4.0%, mean age 73.9 +/- 12.7 in 2010, 2.8%, mean age 71.1 +/- 15.0 in 2015 (P < 0.001). It decreased for both primary (1.8% to 1.0%) and secondary CS (4.1% to 1.8%). The profile of CS patients also changed over time with more patients presenting out-of-hospital cardiac arrest. In both primary and secondary CS, the use of percutaneous coronary intervention increased markedly over time, as did the use of mechanical ventilation and cardiac assist devices. Over the 10-year period, in-hospital mortality remained unchanged for both primary CS (41.8% to 37.8%) or secondary CS (57.3% to 58.8%). However, 1-year mortality decreased in patients with primary CS (from 60% to 37.8%, P = 0.038), and remained unchanged in patients developing secondary CS (from 64.5% to 69.1%, P = 0.731). Conclusion Cardiogenic shock complicating AMI has become less frequent but, if present, CS, and particularly secondary CS, carries a very high mortality, which has not substantially improved over the past 10 years, in spite of the more frequent use of invasive strategies.

Background. - Oxygen therapy remains a cornerstone of treatment for acute heart failure in patients with pulmonary congestion. While avoiding hypoxaemia has long been a goal of critical care practitioners, less attention has been paid to the potential hazard related to excessive hyperoxia. Aim. - To evaluate the impact of early hyperoxia exposure among critically ill patients hospitalized in an intensive care unit for acute heart failure. Methods. - In this preliminary study conducted in a Parisian intensive care unit, we assessed patients with acute heart failure admitted with pulmonary congestion and treated with oxygen therapy from 1 January 2015 to 31 December 2016. The hyperoxia group was defined by having at least one partial pressure of oxygen measurement > 100 mmHg on the first day following admission to the intensive care unit. The primary endpoint was 30-day all-cause mortality. Secondary endpoints were 30-day unplanned hospital admissions, occurrence of infections and intensive care unit and hospital lengths of stay. Results. - Seventy-five patients were included. Forty-three patients (57.3%) presented hyperoxia, whereas 32 patients (42.7%) did not (control group). The baseline clinical characteristics did not differ between the two groups. The primary endpoint was not statistically different between the two groups (14.0% in the hyperoxia group vs 18.8% in the control group; P= 0.85). The secondary endpoints were also not significantly different between the two groups. In the multivariable analysis, hyperoxia was not associated with increased 30-day mortality (odds ratio 0.77, 95% confidence interval 0.24-2.41). Conclusion. - In patients referred to an intensive care unit for acute heart failure, we did not find any difference in outcomes according to the presence of hyperoxia. (C) 2019 Elsevier Masson SAS. All rights reserved.

Idarucizumab is a humanized antigen binding fragment (Fab) of a recombinant anti-dabigatran monoclonal antibody (IgG1-kappa) that allows rapid and sustained reversal of dabigatran-induced anticoagulation in case of bleeding or urgent surgery. Herein, we report a very unusual case of dabigatran reversal by idarucizumab in a 79-year-old woman with acute kidney failure admitted to a hospital in a context of hemoptysis. Three repeated injections were necessary because of massive dabigatran overdose and high rebounds of dabigatran plasma concentration. Idarucizumab was found on urine immunofixation up to 6 days after the last injection where it reacted with anti-kappa light chain antibody, but not with anti-gamma heavy chain antibody. Physicians should be aware of the increased half-life of idarucizumab in this context of acute kidney impairment and of its interference with urine immunofixation because it could lead to false-positive results and misdiagnosis of a paraprotein.

Refractory cardiogenic shock patients may be rescued by veno-arterial extracorporeal membrane oxygenation (VA ECMO). After a few days of mechanical assistance, the device can sometimes be successfully removed if the patient has partially or fully recovered from the condition that required the use of ECMO. The percentage of patients with refractory cardiogenic shock who are successfully weaned from ECMO varies from 31% to 76%. Weaning does not mean survival, because 20% to 65% of patients weaned from VA ECMO support do not survive to hospital discharge. The high death rate after successful weaning shows that many questions remain unresolved in this field. In this review, we will discuss the various factors influencing survival and a successful weaning from VA ECMO, in addition to weaning approaches proposed in the literature. Based on this information, we will propose a strategy to optimize the weaning process.