Background Correct epidural catheter (EC) placement is essential for effective epidural analgesia (EA) during labour, yet confirmation remains indirect. B-mode ultrasound facilitates EA placement but does not reliably visualise the EC. Alternative modalities such as M-mode and colour Doppler (cD) ultrasonography may improve EC localisation, though evidence in obstetrics remains limited. This study evaluated the feasibility of detecting the EC within the epidural space (ES) using M-mode, with secondary objectives of comparing the diagnostic performance of both modes. Methods We conducted a prospective single-centre observational study including 100 parturients requesting EA. After EC insertion, parasagittal oblique and transverse ultrasound views were obtained. For EC location, M-mode detected a granular pattern at the catheter depth in the ES after saline injection, while cD detected saline flow as colour aliasing. EA effectiveness was assessed 20 minutes post-insertion. Results M-mode localised the EC in 48% of cases, all with effective EA (sensitivity 49%, specificity 100%, positive predictive value (PPV) 100%, negative predictive value (NPV) 4%). Using cD, the EC was visualised in 76% of cases (sensitivity 78%, specificity and PPV 100%, NPV 8%) with faster detection (p < 0.001). Considering either modality increased sensitivity to 87%, with specificity and PPV 100% and NPV 13%. Among 15 cases undetected by either mode, EA failed in two, requiring catheter repositioning. Conclusion cD is more sensitive and faster than M-mode for EC localisation in obstetrics. Neither technique alone suffices for systematic screening, but a combined approach markedly improves detection. Absence of EC visualisation could not be interpreted as incorrect placement.

L’échographie périmédullaire a connu un réel essor dans la pratique clinique au cours des dernières décennies. Elle fournit des informations cruciales, telles que le niveau de ponction optimal, la distance entre la peau et le ligament jaune, ainsi que l’angulation requise pour réaliser la ponction. Ces données facilitent la mise en œuvre des techniques d’anesthésie périmédullaire, améliorent leur efficacité tout en augmentant la satisfaction des patient.e.s. Principalement utilisée pour l’écho-repérage des structures avant le geste, cette technique s’acquiert relativement rapidement. L’échoguidage nécessite un apprentissage plus long et plus approfondi. L’échographie périmédullaire est actuellement un atout précieux pour effectuer des blocs neuro-axiaux chez les patients ayant un abord rachidien difficile. La maîtrise de cette technique tend progressivement à devenir indispensable à l’instar des blocs échoguidés.

BACKGROUND:An early diagnosis of a postpartum hemorrhage (PPH) can be challenging. The Shock Index (SI), the ratio of heart rate to systolic blood pressure, appears to be a useful indicator for the early diagnosis of severe PPH after vaginal delivery. Our primary aim was to evaluate if the SI has a predictive value for severe PPH following cesarean section (C-section) under spinal anesthesia (SA) and its best predictive threshold. METHODS:Retrospective single-center trial including women scheduled for C-section under SA with prevention of maternal hypotension by phenylephrine, and complicated by PPH between 2019 and 2021. Women were divided into two groups: non-severe PPH (blood loss <1000 mL) versus severe PPH (blood loss ≥1000 mL). SI was calculated and compared between the groups at four different time points: T0: prior to C-section; T1: at incision; T2: 15 minutes from start of PPH; T3: end of PPH management. Using receiver operating characteristic curve, we calculated the area under the curve (AUC) and the best diagnostic threshold (sensitivity and specificity) for predicting severe PPH. RESULTS:Overall, 129 patients were included, 26 (20.2%) with severe PPH. Median SI was significantly higher at T2 in the severe PPH group (1.14 (1.10-1.25) versus 1.0 (0.85-1.10), P<0.001), but not at other times of management. An SI value of ≥1.17 was the best threshold with an AUC of 0.81 (95% CI 0.72 to 0.90), a sensitivity of 0.42 and a specificity of 0.88. CONCLUSIONS:SI may be an early indicator of severe PPH during C-section under SA.

Background: Hypercapnia worsens lung vascular dysfunction during acute respiratory distress syndrome (ARDS). We tested whether an extracorporeal carbon dioxide removal (ECCO2R) device based on a renal replacement therapy platform (Prismalung®) may reduce PaCO2 and alleviate lung vascular dysfunction in ARDS patients with refractory hypercapnia. Methods: We planned to prospectively include 20 patients with moderate-to-severe ARDS, pulmonary vascular dysfunction on echocardiography, and PaCO2 ≥ 48 mmHg despite instrumental dead space reduction and the increase in respiratory rate. Hemodynamics, echocardiography, respiratory mechanics, and arterial blood gases were recorded at 2 (H2), 6 (H6) and 24 (H24) hours as ECCO2R treatment was continued for at least 24 h. Results: Only eight patients were included, and the study was stopped due to worldwide shortage of ECCO2R membranes and the pandemic. Only one patient fulfilled the primary endpoint criterion (decrease in PaCO2 of more than 20 %) at H2, but this objective was achieved in half of patients (n = 4) at H6. The percentage of patients with a PaCO2 value < 48 mmHg increased with time, from 0/8 (0 %) at H0, to 3/8 (37.5 %) at H2 and 4/8 (50 %) at H6 (p = 0.04). There was no major change in hemodynamic and echocardiographic variables with ECCO2R, except for a significant decrease in heart rate. ECCO2R was prematurely discontinued before H24 in five (62.5 %) patients, due to membrane clotting in all cases. Conclusions: This pilot study testing showed a narrow efficacy and high rate of membrane thrombosis with the first version of the system. Improved versions should be tested in future trials. Trial registration: Registered at clinicaltrials.gov, identifier: NCT03303807, Registered: October 6, 2017, https://clinicaltrials.gov/ct2/show/NCT03303807.

Abstract Background Severe hypothyroidism (SH) is a rare but life-threatening endocrine emergency. Only a few data are available on its management and outcomes of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management, and in-ICU and 6-month survival rates of these patients. Methods We conducted a retrospective, multicenter study over 18 years in 32 French ICUs. The local medical records of patients from each participating ICU were screened using the International Classification of Disease 10th revision. Inclusion criteria were the presence of biological hypothyroidism associated with at least one cardinal sign among alteration of consciousness, hypothermia and circulatory failure, and at least one SH-related organ failure. Results Eighty-two patients were included in the study. Thyroiditis and thyroidectomy represented the main SH etiologies (29% and 19%, respectively), while hypothyroidism was unknown in 44 patients (54%) before ICU admission. The most frequent SH triggers were levothyroxine discontinuation (28%), sepsis (15%), and amiodarone-related hypothyroidism (11%). Clinical presentations included hypothermia (66%), hemodynamic failure (57%), and coma (52%). In-ICU and 6-month mortality rates were 26% and 39%, respectively. Multivariable analyses retained age > 70 years [odds ratio OR 6.01 (1.75–24.1)] Sequential Organ-Failure Assessment score cardiovascular component ≥ 2 [OR 11.1 (2.47–84.2)] and ventilation component ≥ 2 [OR 4.52 (1.27–18.6)] as being independently associated with in-ICU mortality. Conclusions SH is a rare life-threatening emergency with various clinical presentations. Hemodynamic and respiratory failures are strongly associated with worse outcomes. The very high mortality prompts early diagnosis and rapid levothyroxine administration with close cardiac and hemodynamic monitoring.

Background: Hypercapnia worsens lung vascular dysfunction during acute respiratory distress syndrome (ARDS). We tested whether an extracorporeal carbon dioxide removal (ECCO2R) device based on a renal replacement therapy platform (Prismalung®) may reduce PaCO2 and alleviate lung vascular dysfunction in ARDS patients with refractory hypercapnia.Methods: We planned to prospectively include 20 patients with moderate-to-severe ARDS, pulmonary vascular dysfunction on echocardiography, and PaCO2 ≥48 mmHg despite instrumental dead space reduction and the increase in respiratory rate. Hemodynamics, echocardiography, respiratory mechanics, and arterial blood gases were recorded at 2 (H2), 6 (H6) and 24 (H24) hours as ECCO2R treatment was continued for at least 24 hours.Results: Only eight patients were included, and the study was stopped due to worldwide shortage of ECCO2R membranes and the pandemic. Only one patient fulfilled the primary endpoint criterion (decrease in PaCO2 of more than 20%) at H2, but this objective was achieved in half of patients (n=4) at H6. The percentage of patients with a PaCO2 value <48 mmHg increased with time, from 0/8 (0%) at H0, to 3/8 (37.5%) at H2 and 4/8 (50%) at H6 (p=0.04). There was no major change in hemodynamic and echocardiographic variables with ECCO2R, except for a significant decrease in heart rate. ECCO2R was prematurely discontinued before H24 in five (62.5%) patients, due to membrane clotting in all cases.Conclusions: This pilot study testing showed a narrow efficacy and high rate of membrane thrombosis with the first version of the system. Improved versions should be tested in future trials.

Objective : Incidence of right ventricular (RV) failure in septic shock patients is not well-known and Tricuspid annular plane systolic excursion (TAPSE) could be of limited value. We report the incidence of RV failure in patients with septic shock, its potential impact on the response to fluids, as well as TAPSE values. Design : Ancillary study of the HEMOPRED prospective multicenter study including patients under mechanical ventilation with circulatory failure. Setting : Multicenter intensive care unit study Patients : 282 with septic shock were analyzed. Patients were classified in 3 groups based on central venous pressure (CVP) and RV size (RV/LV end-diastolic area, EDA). In group 1, patients had no RV dilatation (RV/LVEDA < 0.6). In group 2, patients had RV dilatation (RV/LVEDA ≥ 0.6) with a CVP < 8 mmHg (no venous congestion). RV failure was defined in group 3 by RV dilatation and a CVP ≥ 8 mmHg. Pulse pressure variation (PPV) was systematically recorded. Interventions : none Measurements and main results : 41% of patients were in group 1, 17% in group 2 and 42% in group 3. A correlation between RV size and CVP was only observed in group 3. Higher RV size was associated with a lower response to passive leg raising for a given PPV. A large overlap of TAPSE values was observed between the 3 groups. 63.5% of patients with RV failure had anormal TAPSE. Conclusions : RV failure, defined by critical care echocardiography (RV dilatation) and a surrogate of venous congestion (CVP ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant PPV. TAPSE was unable to discriminate patients with or without RV failure.

Background : Need for catecholamines is frequent in COVID-19 patients, but the main echocardiographic patterns are unknown. The objective was to report the main echo patterns in critically-ill COVID-19 patients. Methods : Observational and descriptive study in consecutive COVID-19 patients admitted to the ICU between March 12 and May 8, 2020. Systematic critical care echocardiography (CCE) was performed and retrospectively analyzed off-line. Echo values are reported in the overall population and in patients who required catecholamine infusion during the first 2 days following admission (D 1-2 ) or afterwards until day 7 (D 3-7 ). Results : Of the 79 patients (78% male; median age 63 [56-71]; body mass index 29 [26-30]) included, 90% had at least 1 comorbidity. PaO 2 /FiO 2 at admission was 85 [67-162] mmHg. 53% of patients were mechanically ventilated. ICU length of stay was 9 [5-16] days and mortality 34%. 134 echocardiographic studies were performed during the first week in 65 patients. Pulmonary artery acceleration time was decreased (77 [65-97] ms), suggesting pulmonary hypertension. All 39 patients (49%) who required catecholamine infusion underwent CCE and 25.6% had left ventricular (LV) systolic dysfunction, 28.2% acute cor pulmonale (ACP), 7.7% hypovolemia, and 38.5% vasoplegia. Modification of echo patterns was observed at D 3-7 , with less LV systolic dysfunction and more ACP, which was the most frequent pattern. Computed tomography pulmonary angiography in 6 patients with ACP indicated intrapulmonary thrombus in 4. Conclusion : Different echocardiographic patterns were observed during the first week following ICU admission in COVID-19 patients. ACP was frequent and often related to thrombus in the pulmonary circulation.

Introduction Pancreatic surgery is associated with high morbidity, mainly due to infectious complications, so many centres use postoperative antibiotics (ATBpo) for all patients. However, antibiotic regimens vary according to local practices. The aims of this study were to describe the occurrence of surgical site infection (SSI) and ATBpo prescription after pancreatic surgery, and to determine the risk factors of postoperative SSI, in order to better define the clinical indications for ATBpo in this context. Patients and methods All patients undergoing scheduled major pancreatic surgery from January 2007 to November 2018 were included in this retrospective study. Patients were classified into four groups according to SSI and routine ATBpo prescription: SSI+/ATBpo+, SSI-/ATBpo+, SSI+/ATBpo- and SSI-/ATBpo-. In addition, risk factors (fever and pre-operative biliary prosthesis) associated with the occurrence of SSI and ATBpo were analysed using a logistic regression model. Results Data from 149 patients (115 pancreaticoduodenectomies and 34 splenopancreatectomies) were analysed. Thirty (20.1%) patients experienced SSI and 42 (28.2%) received ATBpo. No difference was found in routine ATBpo prescription between patients with and without SSI (26.7% vs 28.6%, respectively; P=0.9). Amongst the 107 patients who did not receive routine ATBpo, 85 (79.4%) did not develop an SSI. In-hospital mortality did not differ between infected and uninfected patients (7% vs 2%, respectively; P=0.13). The occurrence of postoperative fever differed between SSI+ and SSI- patients (73.3% vs 34.2%, respectively; P<0.001), while the prevalence of pre-operative biliary prosthesis was similar (37.9% vs 26.7%, respectively; P=0.3). Conclusion Non-routine ATBpo after major pancreatic surgery resulted in 85 (56%) patients being spared unnecessary antibiotic treatment. This suggests that routine ATBpo prescription could be excessive, but further studies are needed to confirm such antibiotic stewardship. Fever appears to be a relevant clinical sign for individual-based prescription, but the presence of a biliary prosthesis does not.

La chirurgie pancréatique majeure est associée à une importante morbidité, principalement infectieuse, conduisant certains auteurs à proposer une antibiothérapie postopératoire systématique. Cette attitude n'est néanmoins pas consensuelle et les pratiques antibiotiques varient significativement d'un centre à l'autre. Ces prescriptions exposent en outre les patients aux complications potentielles de l'antibiothérapie et aux risques d'émergence de résistance bactérienne. L'objectif de ce travail était d'étudier les pratiques de l'antibiothérapie postopératoire de chirurgie pancréatique majeure et d'identifier des facteurs associés à la survenue d'une infection qui pourraient aider à en préciser les indications. Nous avons mené une étude rétrospective monocentrique dans un centre hospitalo-universitaire. De janvier 2007 à novembre 2018, les patients ayant subi une chirurgie pancréatique majeure réglée ont été inclus dans l'étude. Le critère principal de jugement concernait la prescription systématique postopératoire d'antibiotique (ATB) et la survenue d'une infection du site opératoire (ISO). L'objectif secondaire était d'étudier les facteurs associés aux infections postopératoires (ISO, pneumonie, bactériémie) afin d'identifier les critères cliniques et/ou biologiques pouvant influencer la prescription d'antibiotiques. Cent quarante-neuf patients (115 duodéno-pancréatectomies céphaliques, 34 spléno-pancréatectomies caudales) ont été inclus. Trente patients (20,1 %) ont présenté une ISO et 72 (28,2 %) ont reçu une antibiothérapie systématique. La prescription d'une antibiothérapie postopératoire était similaire entre les groupes de patients ISO+ et ISO− (26,7 versus 28,6 %, p = 0,9). Quatre-vingt-quatre patients (57 %) appartenant au groupe ATB− n'ont pas développé d'ISO, alors que 22 (14,8 %) du même groupe ont développé une ISO. Ces derniers présentaient une mortalité hospitalière significativement plus élevée que les patients du groupe ATB−/ISO− (18,2 versus 0 %, p = 0,002), mais identique aux patients du groupe ATB+/ISO+. La présence d'une prothèse biliaire était similaire dans les groupes ATB−/ISO− et ATB−/ISO+. Une fièvre était plus fréquemment notée dans le groupe ATB−/ISO+ (72,7 versus 33,3 %, p = 0,001). En analyse multivariée, la fièvre était indépendamment associée à la survenue d'une ISO (odds ratio 6,24 [2,4–18,57], p < 0,001). Dans cette série monocentrique, l'antibiothérapie postopératoire systématique après chirurgie pancréatique majeure a été évitée sans conséquence sur la survenue d'une ISO chez plus de la moitié des patients. Cette attitude d'épargne est à mettre en balance avec la survenue d'une ISO responsable d'une surmortalité, mais la fièvre postopératoire semble être un paramètre clinique pertinent pour traiter sans délai une telle complication.

PURPOSE:Bereavement research has helped to improve end-of-life practices in the ICU. However, few studies have explored bereaved relatives experience of research participation in this context. We aimed to explore the experience of bereaved relatives' participation in the ARREVE study which included three telephone follow-up calls to complete several quantitative tools.METHODS:Volunteer relatives who participated in the 12-month follow-up call completed a questionnaire about research participation that included ten open-ended questions so that respondents could use their own words and thoughts. These open-ended questions were analyzed using qualitative analysis that examines themes within the data.RESULTS:175/311 relatives completed the questionnaire. Three themes were derived from the thematic analysis: (1) struggling: reactivation of emotional distress associated with the ICU experience and the loss is frequent, specifically during the 1st follow-up call. (2) Resilience: as time goes by, research participation becomes increasingly positive. The calls are a help both in giving meaning to the relatives' experience and in accepting the loss. (3) Recognition: research calls can compensate for the absence of support during bereavement.CONCLUSION:Although some emotional difficulties must be acknowledged, bereavement research is overall associated with benefits, by facilitating emotional adjustments, meaning-making and resilience. Lack of support and social isolation during bereavement are frequent experiences, revealing that support strategies for bereaved relatives should be developed after the loss of a loved one in the ICU.

OBJECTIVES:Thyroid storm represents a rare but life-threatening endocrine emergency. Only rare data are available on its management and the outcome of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management and in-ICU and 6-month survival rates of patients with those most severe thyroid storm forms requiring ICU admission.DESIGN:Retrospective, multicenter, national study over an 18-year period (2000-2017).SETTING:Thirty-one French ICUs.PATIENTS:The local medical records of patients from each participating ICU were screened using the International Classification of Diseases, 10th Revision. Inclusion criteria were "definite thyroid storm," as defined by the Japanese Thyroid Association criteria, and at least one thyroid storm-related organ failure.MEASUREMENTS AND MAIN RESULTS:Ninety-two patients were included in the study. Amiodarone-associated thyrotoxicosis and Graves' disease represented the main thyroid storm etiologies (30 [33%] and 24 [26%] patients, respectively), while hyperthyroidism was unknown in 29 patients (32%) before ICU admission. Amiodarone use (24 patients [26%]) and antithyroid-drug discontinuation (13 patients [14%]) were the main thyroid storm-triggering factors. No triggering factor was identified for 30 patients (33%). Thirty-five patients (38%) developed cardiogenic shock within the first 48 hours after ICU admission. In-ICU and 6-month postadmission mortality rates were 17% and 22%, respectively. ICU nonsurvivors more frequently required vasopressors, extracorporeal membrane of oxygenation, renal replacement therapy, mechanical ventilation, and/or therapeutic plasmapheresis. Multivariable analyses retained Sequential Organ Failure Assessment score without cardiovascular component (odds ratio, 1.22; 95% CI, 1.03-1.46; p = 0.025) and cardiogenic shock within 48 hours post-ICU admission (odds ratio, 9.43; 1.77-50.12; p = 0.008) as being independently associated with in-ICU mortality.CONCLUSIONS:Thyroid storm requiring ICU admission causes high in-ICU mortality. Multiple organ failure and early cardiogenic shock seem to markedly impact the prognosis, suggesting a prompt identification and an aggressive management.

Repessé, Xavier MD; Ugalde, Diego MD; Vieillard-Baron, Antoine MD, PhD Author Information

PurposeMechanisms of circulatory failure are complex and frequently intricate in septic shock. Better characterization could help to optimize hemodynamic support.MethodsTwo published prospective databases from 12 different ICUs including echocardiographic monitoring performed by a transesophageal route at the initial phase of septic shock were merged for post hoc analysis. Hierarchical clustering in a principal components approach was used to define cardiovascular phenotypes using clinical and echocardiographic parameters. Missing data were imputed.FindingsA total of 360 patients (median age 64 [55; 74]) were included in the analysis. Five different clusters were defined: patients well resuscitated (cluster 1, n=61, 16.9%) without left ventricular (LV) systolic dysfunction, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n=64, 17.7%), patients with hyperkinetic profile (cluster 3, n=84, 23.3%), patients with RV failure (cluster 4, n=81, 22.5%) and patients with persistent hypovolemia (cluster 5, n=70, 19.4%). Day7 mortality was 9.8%, 32.8%, 8.3%, 27.2%, and 23.2%, while ICU mortality was 21.3%, 50.0%, 23.8%, 42.0%, and 38.6% in clusters 1, 2, 3, 4, and 5, respectively (p<0.001 for both).ConclusionOur clustering approach on a large population of septic shock patients, based on clinical and echocardiographic parameters, was able to characterize five different cardiovascular phenotypes. How this could help physicians to optimize hemodynamic support should be evaluated in the future.

Evaluation of intrathoracic pressure is the cornerstone of the understanding of heart-lung interactions, but is not easily feasible at the bedside.Esophageal pressure (P es ) has been shown to be a good surrogate for intrathoracic pressure and can be more easily measured using a small esophageal catheter, but is not routinely employed.It can provide crucial information for the study of heart-lung interactions in both controlled and spontaneous ventilation.This review presents the physiological basis, the technical aspects and the value in clinical practice of the measurement of P es .

We sought to determine the diagnostic ability of the end-expiratory inferior vena cava diameter (IVCEE) to predict fluid responsiveness (FR) and the potential confounding effect of intra-abdominal pressure (IAP).

Les endocardites infectieuses (EI) sont des pathologies graves, dont la prise en charge pluridisciplinaire est recommandée. Nous nous sommes intéressés aux différences selon le pathogène incriminé dans notre cohorte d'EI suivie de manière pluridisciplinaire. Cohorte prospective comparative d'EI suivie 1 an post-fin de traitement par une équipe pluridisciplinaire de 2016 à 2017. Toutes les suspicions d'EI de notre hôpital sont revues par une équipe pluridisciplinaire (infectiologue, cardiologue, réanimateur, microbiologiste, chirurgien et radiologue) qui statue sur le diagnostic définitif, le bilan à réaliser et la stratégie thérapeutique. Présentation des caractéristiques cliniques, microbiologiques et pronostiques selon la bactérie identifiée. Une différence était considérée comme significative si p < 0,05. Au total, 32 suspicions d'EI ont été vus par l'équipe pluridisciplinaire, 26 ont été retenues avec le diagnostic d'EI et inclues dans la cohorte dans un hôpital universitaire de 545 lits de MCO. Un seul patient a présenté une EI à Pseudomonas aeruginosa. Parmi les 25 cas restants, on dénombrait 7 EI à streptocoque, 9 à entérocoque et 9 à Staphylococcus aureus. L'âge moyen global était de 71,0 ans. Parmi les antécédents, 9 (36,0 %) patients étaient diabétiques et 12 (48,0 %) présentaient une valvulopathie sans différence significative selon le type de bactérie incriminée. Un matériel intracardiaque était présent dans 13 cas (52,0 %) et était significativement plus fréquent en cas d'endocardite à entérocoque (66,7 %) et à S. aureus (66,7 %). Les patients présentaient de la fièvre dans 21 cas (84,0 %) et significativement moins fréquemment au cours des EI à entérocoque (55,6 %). Globalement, les patients bénéficiaient d'une intervention dans 7 (28,0 %) cas. Le taux de décès était de 32,0 %. Les EI à S. aureus étaient significativement associées à plus de complications cardiaques liées à une destruction valvulaire (77,8 % vs 56,0 %), plus de choc septique (44,4 % vs 16,0 %), et plus de prise en charge en réanimation (88,9 % vs 60,0 %) et de décès (44,4 % vs 32,0 %). Mais, elles n'étaient pas significativement associées à plus de complications neurologiques (33,3 % vs 36,0 %). Au cours des EI, les EI à entérocoque semblent plus souvent apyrétique et plus souvent liées à des dispositifs intracardiaques, alors que les EI à Staphylococcus aureus semblent associées à une mortalité plus importante liée à des complications cardiaques et septiques, mais pas à des complications neurologiques.