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BACKGROUND & AIMS: Malnutrition following intensive care unit (ICU) stay is frequent and could be especially prominent in critically ill Coronavirus Disease 2019 (COVID-19) patients as they present prolonged inflammatory state and long length stay. We aimed to determine the prevalence of malnutrition in critically ill COVID-19 patients both at the acute and recovery phases of infection. METHODS: We conducted a prospective observational study including critically ill COVID-19 patients requiring invasive mechanical ventilation discharged alive from a medical ICU of a university hospital. We collected demographic, anthropometric and ICU stay data (SAPS2, recourse to organ support and daily energy intake). Nutritional status and nutritional support were collected at one month after ICU discharge (M1) by phone interview and at 3 months after ICU discharge (M3) during a specialized and dedicated consultation conducted by a dietitian. Malnutrition diagnosis was based on weight loss and body mass index (BMI) criteria following the Global Leadership Initiative on Malnutrition. Primary outcome was the prevalence of malnutrition at M3 and secondary outcomes were the evolution of nutritional status from ICU admission to M3 and factors associated with malnutrition at M3. RESULTS: From march 13th to may 15th, 2020, 38 patients were discharged alive from the ICU, median [IQR] age 66 [59-72] years, BMI 27.8 [25.5-30.7] kg/m2 and SAPS2 47 [35-55]. Thirty-three (86%) patients were followed up to M3. Prevalence of malnutrition increased during the ICU stay, from 18% at ICU admission to 79% at ICU discharge and then decreased to 71% at M1 and 53% at M3. Severe malnutrition prevailed at ICU discharge with a prevalence of 55% decreasing 32% at M3. At M3, the only factors associated with malnutrition in univariate analysis were the length of invasive mechanical ventilation and length of ICU stay (28 [18-44] vs. 13 [11-24] days, P = 0.011 and 32 [22-48] vs. 17 [11-21] days, P = 0.006, respectively), while no ICU preadmission and admission factors, nor energy and protein intakes distinguished the two groups. Only 35% of undernourished patients at M3 had benefited from a nutritional support. CONCLUSION: Malnutrition is frequent, protracted and probably underrecognized among critically ill Covid-19 patients requiring invasive mechanical ventilation with more than half patients still being undernourished three months after ICU discharge. A particular attention should be paid to the nutritional status of these patients not only during their ICU stay but also following ICU discharge.

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BACKGROUND: Extracorporeal CO2 removal (ECCO2R) could be a valuable additional modality for invasive mechanical ventilation (IMV) in COPD patients suffering from severe acute exacerbation (AE). We aimed to evaluate in such patients the effects of a low-to-middle extracorporeal blood flow device on both gas exchanges and dynamic hyperinflation, as well as on work of breathing (WOB) during the IMV weaning process. STUDY DESIGN AND METHODS: Open prospective interventional study in 12 deeply sedated IMV AE-COPD patients studied before and after ECCO2R initiation. Gas exchange and dynamic hyperinflation were compared after stabilization without and with ECCO2R (Hemolung, Alung, Pittsburgh, USA) combined with a specific adjustment algorithm of the respiratory rate (RR) designed to improve arterial pH. When possible, WOB with and without ECCO2R was measured at the end of the weaning process. Due to study size, results are expressed as median (IQR) and a non-parametric approach was adopted. RESULTS: An improvement in PaCO2, from 68 (63; 76) to 49 (46; 55) mmHg, p = 0.0005, and in pH, from 7.25 (7.23; 7.29) to 7.35 (7.32; 7.40), p = 0.0005, was observed after ECCO2R initiation and adjustment of respiratory rate, while intrinsic PEEP and Functional Residual Capacity remained unchanged, from 9.0 (7.0; 10.0) to 8.0 (5.0; 9.0) cmH2O and from 3604 (2631; 4850) to 3338 (2633; 4848) mL, p = 0.1191 and p = 0.3013, respectively. WOB measurements were possible in 5 patients, indicating near-significant higher values after stopping ECCO2R: 11.7 (7.5; 15.0) versus 22.6 (13.9; 34.7) Joules/min., p = 0.0625 and 1.1 (0.8; 1.4) versus 1.5 (0.9; 2.8) Joules/L, p = 0.0625. Three patients died in-ICU. Other patients were successfully hospital-discharged. CONCLUSIONS: Using a formalized protocol of RR adjustment, ECCO2R permitted to effectively improve pH and diminish PaCO2 at the early phase of IMV in 12 AE-COPD patients, but not to diminish dynamic hyperinflation in the whole group. A trend toward a decrease in WOB was also observed during the weaning process. Trial registration ClinicalTrials.gov: Identifier: NCT02586948.

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RATIONALE: COVID-19 ARDS could differ from typical forms of the syndrome. OBJECTIVE: Pulmonary microvascular injury and thrombosis are increasingly reported as constitutive features of COVID-19 respiratory failure. Our aim was to study pulmonary mechanics and gas exchanges in COVID-2019 ARDS patients studied early after initiating protective invasive mechanical ventilation, seeking after corresponding pathophysiological and biological characteristics. METHODS: Between March 22 and March 30, 2020 respiratory mechanics, gas exchanges, circulating endothelial cells (CEC) as markers of endothelial damage, and D-dimers were studied in 22 moderate-to-severe COVID-19 ARDS patients, 1 [1-4] day after intubation (median [IQR]). MEASUREMENTS AND MAIN RESULTS: Thirteen moderate and 9 severe COVID-19 ARDS patients were studied after initiation of high PEEP protective mechanical ventilation. We observed moderately decreased respiratory system compliance: 39.5 [33.1-44.7] mL/cmH2O and end-expiratory lung volume: 2100 [1721-2434] mL. Gas exchanges were characterized by hypercapnia 55 [44-62] mmHg, high physiological dead-space (VD/VT): 75 [69-85.5] % and ventilatory ratio (VR): 2.9 [2.2-3.4]. VD/VT and VR were significantly correlated: r2 = 0.24, p = 0.014. No pulmonary embolism was suspected at the time of measurements. CECs and D-dimers were elevated as compared to normal values: 24 [12-46] cells per mL and 1483 [999-2217] ng/mL, respectively. CONCLUSIONS: We observed early in the course of COVID-19 ARDS high VD/VT in association with biological markers of endothelial damage and thrombosis. High VD/VT can be explained by high PEEP settings and added instrumental dead space, with a possible associated role of COVID-19-triggered pulmonary microvascular endothelial damage and microthrombotic process.

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BACKGROUND: Clinical features and outcomes of patients with spontaneous ilio-psoas hematoma (IPH) in intensive care units (ICUs) are poorly documented. The objectives of this study were to determine epidemiological, clinical, biological and management characteristics of ICU patients with IPH. METHODS: We conducted a retrospective multicentric study in three French ICUs from January 2006 to December 2014. We included IPH diagnosed both at admission and during ICU stay. Surgery and embolization were available 24 h a day for each center, and therapeutic decisions were undertaken after pluridisciplinary discussion. All IPHs were diagnosed using CT scan. RESULTS: During this period, we identified 3.01 cases/1000 admissions. The mortality rate of the 77 included patients was 30 %. In multivariate analysis, we observed that mortality was independently associated with SAPS II (OR 1.1, 95 % CI [1.013-1.195], p = 0.02) and with the presence of hemorrhagic shock (OR 67.1, 95 % CI [2.6-1691], p = 0.01). We found IPH was related to anticoagulation therapy in 56 cases (72 %), with guideline-concordant reversal performed in 33 % of patients. We did not found any association between anticoagulant therapy type and outcome. CONCLUSION: We found IPH is an infrequent disease, with a high mortality rate of 30 %, mostly related to anticoagulation therapy and usually affecting the elderly. Management of anticoagulation-related IPH includes a high rate of no reversal of 38 %.

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BACKGROUND: The accurate prediction of outcome after out-of-hospital cardiac arrest (OHCA) is of major importance. The recently described Full Outline of UnResponsiveness (FOUR) is well adapted to mechanically ventilated patients and does not depend on verbal response. OBJECTIVE: To evaluate the ability of FOUR assessed by intensivists to accurately predict outcome in OHCA. METHODS: We prospectively identified patients admitted for OHCA with a Glasgow Coma Scale below 8. Neurological assessment was performed daily. Outcome was evaluated at 6 months using Glasgow-Pittsburgh Cerebral Performance Categories (GP-CPC). RESULTS: Eighty-five patients were included. At 6 months, 19 patients (22%) had a favorable outcome, GP-CPC 1-2, and 66 (78%) had an unfavorable outcome, GP-CPC 3-5. Compared to both brainstem responses at day 3 and evolution of Glasgow Coma Scale, evolution of FOUR score over the three first days was able to predict unfavorable outcome more precisely. Thus, absence of improvement or worsening from day 1 to day 3 of FOUR had 0.88 (0.79-0.97) specificity, 0.71 (0.66-0.76) sensitivity, 0.94 (0.84-1.00) PPV and 0.54 (0.49-0.59) NPV to predict unfavorable outcome. Similarly, the brainstem response of FOUR score at 0 evaluated at day 3 had 0.94 (0.89-0.99) specificity, 0.60 (0.50-0.70) sensitivity, 0.96 (0.92-1.00) PPV and 0.47 (0.37-0.57) NPV to predict unfavorable outcome. CONCLUSION: The absence of improvement or worsening from day 1 to day 3 of FOUR evaluated by intensivists provides an accurate prognosis of poor neurological outcome in OHCA.

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INTRODUCTION: Tracheal rupture is one of the most serious post-intubation complication. However, it is widely underestimated. CLINICAL CASE: An 86-year-old patient with a history of pancreas adenocarcinoma treated with gemcitabin was admitted in intensive care unit for an acute respiratory failure with no identified etiology. The worsening of her respiratory status required invasive mechanical ventilation. One laryngoscopy, performed by a trained operator, found a Cormack 1. Intubation was realized without stylet and the cuff inflated with a syringe. Hemodynamic instability, impaired gas exchange and an extensive subcutaneous emphysema occurred immediately. A CT-scan showed a supracarinal tracheal rupture. COMMENT: The etiological analysis of this case identifies several causes of pars membranosa fragility, such as female sex, age greater than 50 years and the short stature. The emergency intubation and the cuff inflated by a syringe were the risk factors of tracheal rupture in this patient. CONCLUSION: Special care should be paid to this complication, early diagnosis has probably a prognostic value. Training operators in the use of stylets and monitoring cuff pressure are required.

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There is no consensus on optimal screening procedures for multidrug-resistant Enterobacteriaceae (MDRE) in intensive care units (ICUs). Therefore, we assessed five strategies for the detection of extended-spectrum beta-lactamase (ESBL) and high-level expressed AmpC cephalosporinase (HL-CASE) producers. During a 3-month period, a rectal screening swab sample was collected daily from every ICU patient, from the first 24 h to the last day of ICU stay. Samples were plated on MDRE-selective media. Bacteria were identified using MALDI-TOF mass spectrometry and antibiograms were performed using disk diffusion. MDREs were isolated from 682/2348 (29.0%) screening samples collected from 93/269 (34.6%) patients. Incidences of patients with ESBL and HL-CASE producers were 17.8 and 19.3 per 100 admissions, respectively. In 48/93 patients, MDRE carriage was intermittent. Compared with systematic screening at admission, systematic screening at discharge did not significantly increase the rate of MDRE detection among the 93 patients (62% vs. 70%). In contrast, screening at admission and discharge, screening at admission and weekly thereafter, and screening at admission and weekly thereafter and at discharge significantly increased MDRE detection (77%, p 0.02; 76%, p 0.01; 86%, p<0.001, respectively). The difference in MDRE detection between these strategies relies essentially on the levels of detection of patients with HL-CASE producers. The most reasonable strategy would be to collect two samples, one at admission and one at discharge, which would detect 87.5% of the ESBL strains, 67.3% of the HL-CASE strains and 77.4% of all MDRE strains. This study should facilitate decision-making concerning the most suitable screening policy for MDRE detection in a given ICU setting.

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BACKGROUND: Patients aged >80 years represent a growing population admitted to intensive care units (ICUs). However, little is known about ICU-acquired infection (IAI) in this population, and the rate of invasive procedures is increasing. AIM: To evaluate the frequency and effects of IAI in elderly (≥80 years) and younger patients. METHODS: Retrospective evaluation of consecutive patients hospitalized for three days or more over a three-year period in an 18-bed ICU in an academic medical centre. FINDINGS: Elderly patients represented 18.9% of the study population. At admission, the mean number of organ dysfunctions was similar in elderly and younger patients. The use of invasive procedures was also similar in elderly and younger patients, as follows: invasive mechanical ventilation for more than two days, 67.4% vs 55%; central venous catheterization, 56.9% vs 51.4%; and renal replacement therapy, 17.6% vs 17.8%, respectively. The frequency of IAI was 16.5% in elderly patients and 13.9% in younger patients (P = 0.28), with 20.5 vs 18.9 IAI episodes per 1000 ICU-days, respectively (P = 0.2). A Cox model identified central venous catheterization and invasive mechanical ventilation for more than two days as independent risk factors for IAI. The associations between IAI and prolonged ICU stay, increased nursing workload, and ICU and hospital mortality rates were similar in elderly and younger patients. CONCLUSIONS: The frequency of IAI was similar in elderly and younger patients, as were the associations between IAI and length of ICU stay, nursing workload and ICU mortality in an ICU with a high rate of invasive procedures.

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The aim of this study was to describe the features of a large cohort of patients with postoperative mediastinitis, with particular regard to Gram-negative bacteria (GNB), and assess their outcome. This bicentric retrospective cohort included all patients who were hospitalized in the Intensive Care Unit with mediastinitis after cardiac surgery during a 9-year period. Three hundred and nine patients developed a mediastinitis with a mean age of 65 years and a mean standard Euroscore of six points. Ninety-one patients (29.4%) developed a GNB mediastinitis (GNBm). Of the 364 pathogens involved, 103 GNB were identified. GNBm were more frequently polymicrobial (44% versus 3.2%; p <0.001). Being female was the sole independent risk factor of GNBm in multivariate analysis. Initial antimicrobial therapy was significantly more frequently inappropriate with GNBm compared with other microorganisms (24.6% versus 1.9%; p <0.001). Independent risk factors for inappropriateness of initial antimicrobial treatment were GNBm (OR = 8.58, 95%CI 2.53-29.02, p 0.0006), and polymicrobial mediastinitis (OR = 4.52, 95%CI 1.68-12.12, p 0.0028). GNBm were associated with more drainage failure, secondary infection, need for prolonged mechanical ventilation and/or use of vasopressors. Thirty-day hospital mortality was significantly higher with GNBm (31.9 % versus 17.0%; p 0.004). GNBm was identified as an independent risk factor of hospital mortality (OR = 2.31, 95%CI 1.16-4.61, p 0.0179).

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INTRODUCTION: The outcome of acute respiratory failure (ARF) affecting patients with various interstitial lung diseases (ILD) is poorly defined particularly in those with drug-induced ILD (DI-ILD). We investigated this issue focusing on fibrosing idiopathic interstitial pneumonitis (FIIP) and DI-ILD. METHODS: We carried out a retrospective study of patients with ILD admitted in a single center ICU. The primary end-point was in-hospital mortality. RESULTS: We included 72 subjects who fell into 3 diagnostic groups: DI-ILD (n=20), FIIP (n=28) and miscellaneous (M-ILD) (n=24). In-hospital mortality rates were 40% (n=8/20), 68% (n=19/28), and 25% (n=6/24) for DI-ILD, FIIP and M-ILD, respectively, (p=0.006). It reached, 64% (n=7/11), 100% (n=17/17) and 60% (n=6/10), respectively, in subjects on mechanical ventilation (p=0.007). In multivariate analysis, the need for mechanical ventilation (OR= 35; [95% CI, 5-255]), the type of ILD (FIIP vs miscellaneous) (OR=22; [95% CI, 3-147]) and high-dose steroids during ICU stay (OR=0.19; [95% CI, 0.04-0.99]) were independent determinants of in-hospital mortality. CONCLUSION: This study, while confirming the poor prognosis of FIIP patients in ICU, highlights the better prognosis of DI-ILD and M-ILD even though severity criteria on admission are similar in these 3 groups. These data impact on the management of these patients in ICU in whom a proper diagnostic of the underlying condition is crucial.

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Non-invasive ventilation (NIV) is a very effective technique for severe acute exacerbations of COPD/COLD and acute pulmonary edema, but its interest is still a matter of debate for severe asthma attacks. However, despite a slow decrease in asthma mortality, which actually mainly concerns older people, the prevalence of asthma is still raising and is associated to a high level of emergency visits and ICU hospitalizations for severe asthma attacks. Unfortunately, the level of knowledge on this topic is based only on observational studies and on 4 small RCTs, likely to be underpowered to demonstrate any benefit on the rate of tracheal intubation or on mortality. Nevertheless, some benefits have been shown with regard to functional improvement and length of hospital stay. From a technical point of view, one can expect in the future some improvements by combining NIV and nebulization and/or helium-oxygen therapy. Finally, there is a need for positive large randomized clinical trials before routine clinical use can be firmly recommended.

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PURPOSE: Pneumonia is the most common infectious complication of drowning. Pneumonia is potentially life threatening and should be treated by effective antibiotic therapy. However the risk factors, microbiological causes, diagnostic approach and appropriate therapy for pneumonia associated with drowning are not well described. The microbiological ecology of the body of water where immersion occurred could be of import. The aim of this study was to report on microorganisms involved in pneumonia associated with drowning and out of hospital cardiac arrest after successful cardiopulmonary resuscitation. Additionally, we retrieved and undertook microbiological analysis on samples of water from our local river. METHODS: This retrospective study included all patients having suffered an out of hospital cardiac arrest due to drowning and admitted to our tertiary care academic hospital between 2002 and 2010. Data concerning bacteriological lung samples (tracheal aspirate or bronchoalveolar lavage) at admission were reported and compared to bacteriological samples obtained from our local river (the river Seine). RESULTS: A total of thirty-seven patients were included in the study. Lung samples were obtained for twenty-one of these patients. Lung samples were positive in nineteen cases, with a high frequency of multi-drug resistant bacteria. Samples from the Seine River found microorganisms similar to those found in drowning associated pneumonia. CONCLUSIONS: Drowning associated pneumonia can be due to multi drug resistant bacteria. When treating drowning associated pneumonia, antibiotics should be effective against bacteria similar to those found in the body of water where immersion occurred.

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Helium is a low-density inert gas whose physical properties are very different from those of nitrogen and oxygen. Such properties could be clinically useful in the adult critical care setting, especially in patients with upper to more distal airway obstruction requiring moderate to intermediate levels of FiO2. However, despite decades of utilization and reporting, it is still difficult to give any firm clinical recommendation in this setting. Numerous case reports are available in the context of upper airway obstruction of different origins, but there is a lack of controlled studies for this indication. One study reported a helium-induced beneficial effect on surrogates of work of breathing after extubation in non-COPD patients, possibly in relation to laryngeal consequences of tracheal intubation. Physiological benefits of helium-oxygen breathing have been demonstrated in the context of acute severe asthma, but there is a lack of large controlled studies demonstrating an effect on pertinent clinical endpoints, except for a study reported only as an abstract, which mentioned a reduction in the intubation rate in helium-treated patients. Finally, there are a number of physiological studies in the context of COLD-COPD patients demonstrating a beneficial effect, mainly by a reduction in the resistive inspiratory work of breathing but also by a reduction in hyperinflation. Reduction of hypercapnia was mainly observed in spontaneously breathing and noninvasively ventilated helium-treated patients but not in intubated patients during controlled ventilation, suggesting that the decrease in PaCO2 was mainly in relation to a diminution in CO2 production, related to the diminution in work of breathing and not an improved alveolar ventilation. Moreover, there is little evidence that helium-oxygen could improve parameters of heterogeneity in such patients. Two RCTs were unable to demonstrate a reduction in the intubation rate in such setting, but they were likely underpowered. An adequately powered international multicentric study is ongoing and will help to determinate the exact place of the helium-oxygen mixture in the future. The place of the mixture during the weaning period will deserve further evaluation.

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Human toxocarosis is a helminthozoonosis due to the migration of toxocara species larvae throughout the human body. Lung manifestations vary and range from asymptomatic infection to severe disease. Dry cough and chest discomfort are the most common respiratory symptoms. Clinical manifestations include a transient form of Loeffler's syndrome or an eosinophilic pneumonia. We report a case of bilateral pneumonia in an 80 year old caucasian man who developed very rapidly an acute respiratory distress syndrome, with a PaO2/FiO2 ratio of 55, requiring mechanical ventilation and adrenergic support. There was an increased eosinophilia in both blood and bronchoalveolar lavage fluid. Positive toxocara serology and the clinical picture confirmed the diagnosis of the "visceral larva migrans" syndrome. Intravenous corticosteroid therapy produced a rapid rise in PaO2/FiO2 before the administration of specific treatment. A few cases of acute pneumonia requiring mechanical ventilation due to toxocara have been published but this is, to our knowledge, is the first reported case of ARDS with multi-organ failure.

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OBJECTIVE: The aim of our study is to evaluate seven flow rate regulators (FRR) to assess the reliability of these devices compared to standard perfuser with roller clamp. STUDY DESIGN: Each FRR was tested with 5% dextrose and 0.9% sodium chloride combined with three different theoretical flow rates (30, 80 and 250 ml/h). Accuracy was compared with the theoretical value. Repeatability of flow rate was assessed thanks to variance break-up. RESULTS: Each FFR exhibits at least one combination "flow rate-solution" significantly different of the theoretical flow rate. Exadrop was the least successful of the FFR according to the accuracy. This FFR had for each combination a flow rate different of the theoretical (mean error: -24.0 ml/h). Tutodrop was the most successful of the FFR according to the accuracy with five combinations comparable to the theoretical value (mean error: -1.2 ml/h). The standard perfuser with roller clamp, used without FRR, reported two combinations comparable to the theoretical value and showed lowest rates for repeatability. CONCLUSION: Our study exhibits the poor performances of the FRR studied: according to expected flow regulation, the reported results demonstrate the lack of accuracy. Their only one value added compare to the roller clamp is to improve the repeatability of the flow rate.

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We report a case of meningoencephalitis following influenza vaccine revealed by status epilepticus. The patient, an 82-year-old man who had been vaccinated against influenza two days before, had a favourable outcome after intensive care admission including mechanical ventilation. Neurologic side effects have been previously described after influenza vaccination. Although confirmation's exams do not exist, diagnosis is based on imputability criteria, with a complete aetiologic check-up in particular microbiologic check-up. This case, illustrated by modern techniques of biology and imaging, completes the rare and old cases already described in the literature.

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Two cases of invasive aspergillosis (IA) in immunocompetent patients with a fulminant fatal outcome are reported. Both patients were elderly and had a history of chronic lung disease treated with prolonged inhaled corticosteroids and a short course of systemic corticosteroids. They presented with dyspnea and fever, their respiratory function deteriorated rapidly, and they died 7 days after admission. Aspergillus fumigatus was cultured from respiratory samples. IA was confirmed in one case by necropsy that showed diffuse bilateral necrotizing pneumonitis and myocarditis. In the other case, IA diagnosis was established by thoracic CT scan plus detection of Aspergillus antigen in two blood samples. These two cases demonstrate that short-term corticosteroid therapy in immunocompetent patients with underlying chronic lung conditions is a risk factor for IA, and that its evolution can be fulminant.

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The aim of this study was to assess management of patients resuscitated after pre-hospital cardiac arrest, initially indicated to preserve neurological status, the aetiological investigation only being undertaken when the outcome is favourable. Eighty-nine pre-hospital cardiac arrests were analysed retrospectively. The hospital survival was 16%, death being due to neurological lesions (55%), uncontrollable haemodynamic instability -39%) or other causes (7%). One year after the initial episode, none of the survivors had died, all living autonomously without (8 patients) or with minimal neurological sequellae (5 patients). These results are concordant with reports in the literature. The 11 cases of cardiac arrest with a favourable outcome of presumed cardiac origin underwent coronary angiography (6 cases) or endocavitary electrophysiological investigation (8 cases). These investigations showed or suggested an ischaemic process in 4 cases, an arrhythmia in 6 cases and severe valvular heart disease in 1 case. The independent predictive factors of survival were a Glasgow score of 6 or more on admission, the persistence of a light reflex and benign EEG appearances according to Synek's classification. The authors conclude that these results are comparable to those reported in the literature with aetiological investigations reserved for cases of favourable neurological outcome. The investigations including coronary angiography and electrophysiological investigation are essential as shown by the diversity of the cardiac pathologies identified.

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