OBJECTIVES:To report the prevalence of potentially surgical digestive complications in critically ill patients with status epilepticus (SE), identify the associated factors, and study the association between digestive complications and mortality at hospital discharge. DESIGN:Retrospective analysis of prospectively collected data. SETTING:Twenty-three ICUs. PATIENTS:Adults prospectively included in the ICTAL Registry between February 2018 and July 2025. Inclusion criteria were age 18 years or older and ICU admission for SE. Digestive complications were defined by severe clinical and/or radiologic findings suggestive of a need for surgical intervention, including bowel ileus, colonic dilatation, and/or gut ischemia. A propensity score identified factors associated with digestive complications. Logistic multivariable regression assessed predictors of hospital mortality. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Among 1007 patients, 16 patients (1.6%) developed digestive complications (median age, 58 yr; 37.5% male) at a median of 5 days (interquartile range, 3-9 d) after SE onset. Surgery was required in six patients (37.5%). Paralytic ileus or colonic dilatation occurred in 13 patients (81.3%), and bowel or colonic ischemia in 7 (43.8%). Refractory SE (RSE) and its treatment (propofol, midazolam, thiopental, and ketamine) were significantly associated with digestive complications. In-hospital mortality was higher in patients with digestive complications (50.0% vs. 18.4%; p = 0.005). Digestive complications independently predicted mortality (odds ratio, 3.43; 95% CI, 1.13-10.21; p = 0.03). CONCLUSIONS:Potentially surgical digestive complications in SE were rare but strongly associated with RSE and its treatment. These complications independently predicted hospital mortality.

During severe and critical COVID-19, therapeutic options remain scarce. Among interventions, the use of interleukin-6 receptor inhibitor (IL-6Ri) is especially controversial due to persistent uncertainty about their efficacy and safety. To compare the occurrence of secondary infections, digestive and hematological complication function of the administration of IL-6Ri we conducted a multicentric retrospective French observational study. All severe or critical COVID-19 requiring hospital admission were included. Among 2587 patients requiring hospital admission, 1603 had a severe COVID-19 and 984 a critical one requiring ICU admission. 224 received at least one dose of tocilizumab or sarilumab. Incidence of secondary infection was 29.5

BACKGROUND:Brain death after hanging-induced cardiac arrest is a fatal complication about which few data are available. We aimed at identifying the early predictors of progression to brain death in patients with hanging-induced cardiac arrest. METHODS:Retrospective study including adults with return of spontaneous circulation from hanging-induced cardiac arrest admitted to 34 ICUs in France and Belgium between 2000 and 2024. Logistic multivariate regression was performed to identify factors associated with progression to brain death. RESULTS:Of the 554 patients with hanging-induced cardiac arrest, brain imaging was performed on admission in 443 (80.0%) patients. Overall, 169/554 (30.5%) and 142/443 (32.1%) patients progressed to brain death within a median time of 3 days, and up to 12 days, after the hanging-induced cardiac arrest. In 443 patients with brain imaging, five factors were independently associated with a higher risk of progression to brain death: female (OR, 1.76; 95% CI, 1.06-2.90; p = 0.03), asystole as first recorded rhythm (OR, 2.03; 95% CI, 1.27-3.29; p = 0.004), low-flow time > 30 min (OR, 1.84; 95% CI, 1.07-3.17; p = 0.03), total Logistic Organ Dysfunction System Score at day 1 (OR, 1.93/per point; 95% CI, 1.14-3.29; p = 0.02), and cerebral oedema and/or ischemic complication on brain CT scan at ICU admission (OR, 1.62; 95% CI, 1.01-2.61, p = 0.04). Conversely, age > 50 years (OR, 0.59; 95%CI, 0.35-0.98, p = 0.04) and status myoclonus ≤ day 2 (OR, 0.24; 95%CI, 0.09-0.54, p = 0.001) were associated with a lower risk of progression to brain death after hanging-induced cardiac arrest. CONCLUSION:Our findings emphasise the very high rate of brain death after hanging-induced cardiac arrest. In our population, factors associated with brain death after hanging induced cardiac arrest predominantly reflect initial injury severity.

BACKGROUND:The aim of the DESAC study (Devenir des Survivants d'Arrets Cardiaques) was to describe the survival rate and neurological status of out-of-hospital (out-of-hospital cardiac arrest) survivors, and to assess the influence of prehospital and intrahospital factors. METHODS:Between July 2015 and October 2018, consecutive nontraumatic out-of-hospital cardiac arrest patients aged over 18 years discharged alive from 33 intensive care units in Paris and the suburbs (France) were included. Their neurological status was assessed every 6 months using the Cerebral Performance Category (CPC) scale. Prognostic factors associated with a favorable neurological outcome at 24 months (CPC category of 1 or 2) were assessed by covariate-adjusted logistic regression. Trajectories of CPC level over time were derived using a linear mixed model in survivors with at least 3 repeated assessments. RESULTS:Out of 593 survivors, 525 were followed up for 24 months (mean age, 58.1±15.3 years, 79% males), and 449 of 525 (86%) had a favorable neurological outcome. Initial shockable rhythm (adjusted odds ratio, 3.33 [95% CI, 1.57-7.07]) and previous practice of sport (adjusted odds ratio, 3.13 [95% CI, 1.21-8.12]) were associated with favorable outcome, whereas factors with reduced odds ratio were older age (adjusted odds ratio per 10 years, 0.53 [95% CI, 0.41-0.69]) and prior percutaneous coronary intervention (adjusted odds ratio, 0.38 [95% CI, 0.17-0.85]). Therapeutic hypothermia or acute coronary interventions were not related to prognosis (P>0.05). Overall, among the 514 patients with at least 3 repeated assessments, 5 distinct CPC trajectories (2 reflecting early death were combined) were derived: 64% remained in CPC1, 13.4% in CPC2, 11% improved from CPC2 to CPC1, and 11.6% died either early or lately (>3 months) during follow-up. CONCLUSIONS:This multicentric prospective study indicates that 86% of out-of-hospital cardiac arrest survivors had a favorable neurological outcome at 24 months. Pre-event and intraevent factors (including previous practice of sport and shockable rhythm), but not in-hospital management (therapeutic hypothermia or acute coronary interventions), were associated with a favorable outcome. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT02494414.

OBJECTIVES:Critically ill adult patients who require arterial puncture for arterial blood gas analysis are exposed to pain. We evaluated the potential effect of a vapocoolant spray on reducing pain in this population. METHODS:SNOW study was a multicentre, randomised, single-blind, placebo-controlled, assessor-masked, superiority trial conducted in four intensive care units in French hospitals. We randomly assigned critically ill adult patients (aged ≥18 years) to one of two treatment groups (vapocoolant spray or placebo) before an arterial puncture for arterial blood gas analysis. The primary outcome was the intensity of the patient's visual analogue scale rating of pain immediately after the arterial puncture, as assessed by masked assessors. The analysis is reported in the modified intention-to-treat population, which included all randomised patients except those who withdrew or did not consent to continue and those who did not receive their allocated treatment because they met a criterion for ineligibility. The trial was registered on Clinicaltrials.gov with the identifier NCT03973385. RESULTS:From November 12, 2020, to January 12, 2022, 201 patients were randomised to receive either vapocoolant spray (101 patients) or placebo spray (100 patients); 194 received the allocated intervention and 192 were included in the analysis (96 in each allocation group). In the modified intention-to-treat analysis, both the best and worst scenarios for handling with missing data demonstrated that the use of vapocoolant spray was significantly associated with a lower visual analogue scale pain score at the end of the arterial puncture procedure (effect size [Cohen's d]: -0.30 [95% confidence interval: -0.58 to-0.01] and -0.48 [-0.77 to -0.19], respectively). No instances of serious adverse events were reported. CONCLUSIONS:In critically ill adult intensive care patients, the use of vapocoolant spray reduced pain during arterial puncture for blood gases, without significant side effects.

Introduction Patients discharged from intensive care units (ICUs) are at high risk of adverse long-term outcomes including cardiovascular and/or renal events and a 1-year mortality of approximately 22%. Plasma biomarkers measured at ICU discharge have demonstrated strong prognostic value, with elevated cardiac or renal biomarkers identifying patients at particularly high risk of poor outcomes. Sodium-glucose cotransporter 2 inhibitors are now widely recognised for their cardioprotective and nephroprotective effects in chronic conditions such as type 2 diabetes, heart failure or chronic kidney disease. These agents improve both morbidity and mortality across a range of high-risk populations. We hypothesise that a therapeutic strategy aimed at preventing the progression of cardiovascular and/or renal injury following ICU discharge may improve long-term outcomes in ICU survivors.Method and analysis This is a multicentre, double-blind, randomised, placebo-controlled clinical trial conducted across 16 teaching and non-teaching ICUs in France. We will enrol 600 adult patients (18 years of age or older) who have received mechanical ventilation and/or vasopressors for at least 24 hours during their ICU stay, and who meet at least one of the following criteria at ICU discharge: N-terminal pro-B-type natriuretic peptide (NT-proBNP) >800 pg/mL or BNP >90 ng/L, an estimated glomerular filtration rate between 25 and 90 mL/min/m². Eligible patients will be randomised in a 1:1 ratio to receive either dapagliflozin (10 mg once daily) or a matching placebo for a duration of 1 year. The primary outcome is a composite endpoint assessed at 1 year after randomisation, comprising: all-cause mortality, unscheduled hospitalisation for acute heart failure and decrease in renal function. Feasibility will be assessed based on patient and clinical acceptability and recruitment performance, including enrolment rates across participating centres.Ethics and dissemination This study has been approved by the Institutional Review Board (CPP Ile-de-France 5). Written informed consent will be obtained from all participants prior to enrolment and the initiation of any study-related procedures. Dapagliflozin is a widely available medication with an established safety profile. If proven effective, it would represent a readily deployable strategy to improve long-term outcomes in ICU survivors. The study is described in accordance with the Standard Protocol Items: Recommendations for Interventional Trials framework, and key design features and methodological decisions are outlined accordingly. DAPA-ICU aims to evaluate the efficacy of dapagliflozin in cardiorenal protection among critically ill patients following ICU discharge. The main trial results will be submitted for publication in a peer-reviewed journal as soon as they become available after final analysis.Trial registration number NCT07025629.

To describe the prevalence of PTSD symptoms and their associated factors in nursing students 1 month after the peak of the first COVID-19 wave in France. On-line cross-sectional survey. Nursing school students throughout France. Respondents to the survey conducted between 12 May and 12 July 2020 completed the Impact of Event Scale-Revised (IES-R). Scores ≥ 24 indicate PTSD symptoms of concern. Factors independently associated with scores ≥ 24 were identified by multivariable logistic regression. Of the 4282 respondents (91.3% were females, 77.4% were aged 18–25 years), 1032 (24.1%) reported a prior traumatic event and 1569 (36.6%) had IES-R scores ≥ 24, indicating PTSD symptoms of concern. By multivariable analysis, variables associated with an IES-R score ≥ 24 included pre-existing vulnerabilities (prior traumatic event, psychological support, and psychotropic treatment), working conditions (COVID-19 unit rotation, rotation as full-time registered nurse, team integration issues, out-of-scope tasks, not feeling valued and limited access to protective equipment), management of patients with COVID-19-related life-threatening emergencies, pandemic-related emotional distress (feelings of incompetence and vulnerability, fear of getting infected and infecting relatives), and pandemic-related anxieties (isolation from family, news anxiety, anxiety about missed nursing classes). The ability to rest and recover was the only variable associated with a lower risk of a score ≥ 24. PTSD symptoms of concern were common in nursing students during the first COVID-19 wave. Several factors independently associated with PTSD symptoms are amenable to improvement. Opportunities to rest and recover must be provided (study registered on ClinicalTrials.gov, NCT04402229).

Introduction Status epilepticus (SE) in adults is a serious neurological emergency that can lead to high morbidity and mortality rates. Although functional outcomes are often assessed using general scoring systems, limited data on health-related quality of life (HRQoL) in patients admitted to intensive care units (ICUs) are still limited. Furthermore, comprehensive evaluations of patient-reported physical, cognitive, mental health and psychological outcomes are lacking in this population. POSEIDON 2 aims to assess HRQoL and cognitive, physical and psychological impairments at 3 and 12 months after ICU discharge following SE and quantify caregiver burden.Methods and analysis POSEIDON 2 is a prospective, multicentre, longitudinal study conducted in 19 French ICUs. The study combines data from the SE ICTAL Registry with data from patients who survived admission to the ICU for SE, who will be recruited for the study. The study also includes patient-reported outcome (PRO) data collected 3 (M3) and 12 (M12) months after discharge from the ICU using validated instruments. The Zarit scale will be used to measure the burden on caregivers at M3 and M12. The primary endpoint is the prevalence of overall HRQOL impairment at M3 and M12, as defined by dichotomous scores on the physical and mental components of the 36-Item Short Form Health Survey compared with those of the general population. Secondary endpoints include domain-specific impairments, such as cognitive function, dependence, mental health and patient experiences. The sample size has been calculated based on an estimated prevalence of 75% for HRQoL impairment, with a planned sample size of 140 patients.Ethics and dissemination The POSEIDON 2 study protocol received ethical approval from the ethics committee ‘Comité de Protection des Personnes Ouest VI’ on 5 October 2023 (#2023-A01223-42). The study is conducted in accordance with the Declaration of Helsinki, Good Clinical Practice and the regulatory requirements of France. Written informed consent is obtained from participants, who are able to decline participation or withdraw from the study at any time. Findings will be disseminated through publication in peer-reviewed journals and presentations at scientific conferences.Trial registration number NCT06100978.

INTRODUCTION:Data on sex differences during acute exacerbations of chronic obstructive pulmonary disease (COPD) management and mortality in the intensive care unit (ICU) are scarce. This study aimed to describe and compare sex differences in management and their impact on mortality. METHODS:We conducted a monocentric retrospective cohort study on all patients admitted to our ICU between 2015 and 2022 for a severe acute exacerbation of COPD. Logistic multivariate regression analysis was performed. RESULTS:A total of 508 patients were included, of whom 331 (65.2%) were males and 177 (34.8%) were females. Female patients had a higher proportion of severe COPD (GOLD stage ≥ 3) than males (59.3% vs. 54.4%, p = 0.032), whereas males exhibited significantly more cardiovascular comorbidities. Three-month mortality was 19.3% in males and 18.6% in females (p = 0.84). In multivariate analysis, factors independently associated with 3-month mortality were older age (hazard ratio [HR] per year = 1.04, p = 0.001), immunodeficiency (HR = 1.66, p = 0.022), higher performance status (HR per point = 1.68, p < 0.001), long-term oxygen therapy (HR = 1.80, p = 0.006), and invasive mechanical ventilation (HR = 2.59, 95% CI: 1.34-5.01, p = 0.05). Sex was not associated with 3-month mortality (p = 0.5). CONCLUSION:Despite distinct phenotypes between males and females, management and outcomes of severe COPD exacerbations in ICU were similar, underscoring the need to better understand sex-related determinants in critical COPD care.

Introduction:Data on COPD patients who experience multiple intensive care unit (ICU) admissions for severe acute exacerbations (AECOPD) are scarce. We aimed to describe and compare patients' characteristics by recurrent admission status and to identify factors associated with recurrent ICU-level exacerbations. Methods:We conducted a single-centre, retrospective cohort study including all patients admitted to our ICU between 2015 and 2022 for a severe AECOPD. Patients with more than one ICU admission during the study period were classified as "recurrent exacerbator" phenotype. Multivariable regression and competing-risk models were used. Results:We included 328 patients who had a total of 445 admissions. Seventy-two (22.0%) patients had multiple ICU admissions. Compared with non-recurrent patients, recurrent exacerbators were younger (median 67 vs 70 years, p=0.037), had a lower prevalence of impaired Performance Status (13.9% vs 25.8%, p=0.035), and had higher blood eosinophil counts (0.06 vs 0.04 G/L, p=0.025). One-year mortality was similar between groups (18.1% vs 18.4%, p=0.95). In multivariate model, factors independently associated with recurrent severe exacerbation were long-term oxygen therapy (HR = 1.79, p=0.045) and initial blood eosinophil count (HR per +0.1 G/L = 1.10, p<0.001). A Performance Status ≥3 was inversely associated with recurrence (HR per point = 0.41, p=0.030). Conclusion:Patients with recurrent ICU admission for severe COPD exacerbations were younger and had higher blood eosinophil counts than those with a single admission. These findings may suggest that phenotyping-including blood eosinophils-could help stratify the risk of recurrent severe exacerbations and personalised treatment.

BACKGROUND:Prognostication of recovery in patients who are unconscious following cardiac arrest can be guided by concentrations of brain injury biomarkers in the blood. The optimal biomarker and cutoff concentrations for the prediction of outcome remain unknown. In this study, we aimed to evaluate which biomarker of brain injury is most accurate for predicting functional outcome after cardiac arrest, and to evaluate cutoff levels for the prediction of good and poor outcome. METHODS:This study was a prospective, international, observational biomarker study within the international Targeted Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial including adults aged 18 years or older with a presumed cardiac cause or unknown cause of arrest. Patients were recruited from 24 European hospitals. Serum samples were collected at 0, 24, 48, and 72 h after admission to intensive care units. Concentrations of neuron-specific enolase, S100, neurofilament light, and glial fibrillary acidic protein were analysed with Elecsys electrochemiluminescence immunoassays. The primary outcome was 6-month good (modified Rankin Scale 0-3) or poor (modified Rankin Scale 4-6) functional outcome. Prognostic accuracy was evaluated by the area under the receiver operating characteristic curve (AUROC). The biomarker with the highest AUROC at each timepoint was compared with that of the second highest marker using DeLong's test. As pre-specified, to account for multiple comparisons using Bonferroni correction, a p value of less than 0·0125 was considered statistically significant. FINDINGS:Between April, 2018, and January, 2020, 113 (12%) of 932 eligible patients were excluded due to death, missed sampling, or missing outcome data. 661 (81%) of 819 included patients were male and 158 (19%) were female, the mean age was 64 years (SD 13), and 418 (51%) had a poor outcome. In patients who were unconscious, neurofilament light predicted functional outcome with AUROCs at 0, 24, 48, and 72 h of 0·77 (95% CI 0·73-0·80), 0·92 (0·90-0·94), 0·93 (0·91-0·95), and 0·93 (0·91-0·95), respectively. Glial fibrillary acidic protein achieved an AUROC of 0·74 (95% CI 0·70-0·77) at 0 h, 0·87 (0·84-0·90) at 24 h, 0·87 (0·84-0·90) at 48 h, and 0·87 (0·84-0·91) at 72 h. Neuron-specific enolase predicted functional outcome with an AUROC of 0·61 (95% CI 0·56-0·65) at 0 h, 0·78 (0·75-0·82) at 24 h, 0·85 (0·81-0·88) at 48 h, and 0·86 (0·82-0·89) at 72 h. S100 achieved an AUROC of 0·74 (95% CI 0·71-0·78) at 0 h, 0·84 (0·81-0·87) at 24 h, 0·79 (0·75-0·82) at 48 h, and 0·78 (0·74-0·82) at 72 h. Neurofilament light had a statistically significantly higher AUROC than the second highest marker, glial fibrillary acidic protein, at 24, 48, and 72 h (p<0·0001), but not at 0 h (p=0·27). INTERPRETATION:Neurofilament light is a highly accurate predictor of long-term outcome after cardiac arrest and superior to other relevant biomarkers evaluated in this study. FUNDING:The Swedish Research Council (Vetenskapsrådet), the Swedish Heart-Lung Foundation, the Stig and Ragna Gorthon Foundation, the Knutsson Foundation, the Laerdal Foundation, the Hans-Gabriel and Alice Trolle-Wachtmeister Foundation for Medical Research, the Bundy Academy at Lund University, Regional Research Support in Skåne, the Swedish Government, and Roche Diagnostics International.

Background:Data on withholding life-support (WLS) decisions during acute exacerbations of chronic obstructive pulmonary disease (COPD) in the intensive care unit (ICU) are scarce. This study aimed to identify factors associated with these decisions and their impact on mortality. Methods:We conducted a monocentric retrospective cohort study on all patients admitted to our ICU between 2015 and 2021 for a severe acute exacerbation of COPD. Logistic multivariable regression analysis was performed. Results:We included 463 patients of whom 128 (27.6%) had a decision of withholding of care. The 3-months mortality was 49.2% and 4.8% in the WLS group and in the no WLS group, respectively. Forty-eight patients (10.4%) had advanced healthcare directives. In multivariable analysis, factors associated with a decision of WLS were higher age (odds ratio [+10 years] = 1.93, p < 0.001), immunodeficiency (OR = 3.07, p < 0.001), higher Performance Status (PS) score (OR [+1 point] = 2.10, p < 0.001), long-term oxygen therapy (OR = 4.11, p < 0.001) and shock after ICU admission (OR = 2.43, p = 0.01). In multivariate analysis, factors significantly associated with 3-month mortality included decision of WLS during ICU (OR = 22.98, p < 0.001) and invasive mechanical ventilation (OR = 2.72, p < 0.001). Conclusion:Approximately 30% of COPD patients underwent a decision to withhold life-sustaining treatment. Higher age, immunosuppression, increased PS score, and long-term oxygen therapy were significantly associated with this decision. Nearly half of the patients died within three months following a withholding of care decision.

BACKGROUND AND OBJECTIVES:Clinical outcome assessment (COA), particularly health-related quality of life (HRQoL) is an important component of patient-centered outcome assessment. Few studies have evaluated this in the context of the status epilepticus (SE). The objective of the current study was to describe COAs in patients who had been critically ill with SE. METHODS:We conducted a cross-sectional study in patients previously included in the ICTAL Status Epilepticus Registry between February 2018 and February 2022 in 15 French intensive care units. Eligible patients were invited to complete COA questionnaires covering the following domains: HRQoL, dependency, mental health, cognitive status, and social support. These were performed up to 5 years after the SE episode. RESULTS:The median [IQR] age of the 66 responders was 58 [47, 68] years and 43 patients (65.2 %) were male. A total of 15 patients (22.7 %) had a previous history of epilepsy. Overall, 48 patients (70.7 %) in our cohort presented with worse HRQoL than the general population. Physical and mental composite scores showed similar alterations, with mean (SD) values of 42.1 (11.1) and 42.3 (12.5), respectively. A strong and significant correlation was identified between the 36-item Short-Form (SF-36) total score and domains of dependency and mental health. The search for an association between predictors of poor outcome after SE and HRQoL findings at the time of the cross-sectional assessment in patients with a worse SF-36 score than the reference population was negative for all variables tested. DISCUSSION:We report poorer HRQoL among patients treated for SE. Longitudinal studies are needed to corroborate these findings.

Objective Targeted temperature management (TTM), through its physiological effects on intracranial pressure, may impede the progression to brain death (BD) in severe anoxic brain injury post-cardiac arrest (CA). We examined the potential association between the use of TTM and the occurrence of BD after CA.Design Monocentric, retrospective study.Setting Intensive care unit, Versailles Hospital, France.Participants Comatose survivors of CA who died from BD or postanoxic encephalopathy (PAE) after 24 hours.Main outcome measures PAE deaths corresponded to withdrawal of life-sustaining therapy (WLST) due to irreversible postanoxic coma or vegetative state according to prognostication guidelines. BD corresponded to the cessation of cerebral vascularisation secondary to intracranial hypertension. The diagnosis of BD was definite by clinical diagnosis of deep coma according to the Glasgow Coma Scale 3, loss of all brainstem reflexes and the demonstration of apnoea during a hypercapnia test. A cerebral omputed tomography (CT) scan or two isoelectric and unreactive electroencephalograms were used to confirm BD. To identify the independent association between TTM and BD, we conducted a multivariable logistic regression analysis.Results Out of 256 patients included between 2005 and 2021, 54.3% received TTM for at least 24 hours, and 56 patients (21.9%) died from BD. In the multivariable analysis, TTM for 24 hours or more was not associated with a decrease in BD (Odds Ratio 1.08, 95% CI 0.51 to 2.32). Factors associated with BD included a total duration of no-flow plus low-flow exceeding 30 min, CA due to neurological causes or hanging and a high arterial partial pressure of carbon dioxide between days 1 and 2 after admission.Conclusions This exploratory analysis of post-CA patients with severe anoxic brain injury did not find an association between TTM ≥24 hours and a reduction in BD. Further studies are needed to identify specific subgroups of post-CA patients for whom TTM may be especially futile or even harmful.

Background:Acute intestinal injury plays a major role in the pathophysiology of the post-cardiac arrest (CA) syndrome. Citrulline and intestinal fatty acid-binding protein (I-FABP) are associated with mesenteric ischemia but there is paucity of data regarding their association with upper gastrointestinal tract injury. Methods:We conducted an ancillary analysis of the prospective and multicentric ENTRACT study, in which all patients who remained mechanically ventilated during the first 5 days after out-of-hospital CA underwent an esophago-gastro-duodenoscopy. Patients with available biobank were enrolled and plasma citrulline and I-FABP and urinary I-FABP were measured to assess their association with the severity of upper gastrointestinal tract lesions. Results:The biobank was available for 125 patients, mostly men (75 %) with a median age of 64 [55-72] years. Clinical, biological and CA characteristics were similar between groups according to the presence of severe lesions, except for a higher dose of adrenaline received during cardiopulmonary resuscitation in patients with severe lesions. Plasma citrulline (15 [12.4-19] vs 16.7 [14-21] µmol/L, p = 0.09) and I-FABP (339 [184-1140] vs 493 [271-976] pg/mL, p = 0.50) did not differ according to severe lesions, although urinary I-FABP was higher in the severe lesion group (6560 [1190-18450] vs 2030 [685-7400] pg/mL, p = 0.04). Corresponding performance for prediction of severe upper GI lesions was poor regarding positive and negative predictive values. Conclusion:Citrulline and I-FABP did not reliably predict the presence of severe upper gastrointestinal tract ischemic injury observed during esophago-gastro-duodenoscopy performed within the first 5 days after an out-of-hospital CA.

INTRODUCTION:Acute encephalopathy in the ICU poses significant diagnostic, therapeutic, and prognostic challenges. Standardized expert guidelines on acute encephalopathy are needed to improve diagnostic methods, therapeutic decisions, and prognostication. METHODS:The experts conducted a review of the literature, analysed it according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology and made proposals for guidelines, which were rated by other experts. Only expert opinions with strong agreement were selected. RESULTS:The synthesis of expert work and the application of the GRADE method resulted in 39 recommendations. Among the 39 formalized recommendations, 1 had a high level of evidence (GRADE 1 +) and 10 had a low level of evidence (GRADE 2 + or 2-). These recommendations describe indication for ICU admission, use of clinical scores and EEG for diagnosis, detection of complications, and prognostication. The remaining 28 recommendations were based on expert consensus. These recomandations describe common indications for blood and CSF studies, neuroimaging, use of neuromonitoring, and provide guidelines for management in the acute phase. CONCLUSION:This expert consensus statement aims to provide a structured framework to enhance the consistency and quality of care for ICU patients presenting with acute encephalopathy. By integrating high-quality evidence with expert opinion, it offers a pragmatic approach to addressing the complex nature of acute encephalopathy in the ICU, promoting best practices in patient care and facilitating future research in the field.

Background: Acute circulatory failure after successfull resuscitation of cardiac arrest remains challenging and multifactorial. As the main driver of early mortality after restoration of spontaneous circulation, its therapeutic management essentially relies on fluids administration and vasopressive support using noradrenaline. Data also support the potential impact of a hormonal defect in this setting. Steroids substitution as well as arginivasopressin treatment should be evaluated in these patients. Methods: The HYVAPRESS trial is a 2x2 factorial randomized placebo-controlled multicentric trial evaluating the effect of both hydrocortisone and arginin-vasopressin in successfully resuscitated (inhospital and out-of-hospital) cardiac arrest patients suffering an acute circulatory failure in the first 24 h after restoration of spontaneous circulation. The main outcome will be the favourable neurological outcome assessed by the Glasgow Outcome Scale (GOS). 380 patients will be included, i.e. 95 patients in each arm, allowing the detection of a 15% difference in mortality using a power of 80% Discussion: Assessing therapeutics in the hemodynamic failure in post cardiac arrest patients is challenging as the mortality is very high. Besides the vasopressive support, few investigation have been led so far to improve the management of these patients. While hydrocortisone and argininvasopressive have been evaluated in septic shock patients, data are lacking in this very specific subgroup of patients suffering from a very high Trial registration: Clinical Trials NCT04591990, registered on 2020, October 19th.