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Purpose: Cervical necrotizing fasciitis (CNF) is a severe and debilitating disease that requires intensive care unit (ICU) management and prompt surgical treatment to reduce morbidity and mortality. The aim of this study was to estimate the incidence and factors associated with severe complications of CNF., Methods: We reviewed the medical records of consecutive patients hospitalized in an ICU from 2007 to 2012. The data were collected retrospectively; initial cervical and thoracic computed tomography (CT) scans, performed on admission, were reviewed by an experienced and blinded radiologist to determine CNF complications., Results: A cohort of 160 patients admitted for CNF was included. The following complications of CNF were found: bilateral extension of CNF (28%), internal jugular vein thrombosis (21%), descending necrotic effusion (14%), mediastinitis (24%), and mortality (4%); 53% had at least one complication, and 48% had at least one cervical complication. On the basis of a univariate analysis, the significant independent factors are odynophagia, dyspnea, oral glucocorticoids intake before admission, and pharyngeal source. Oral nonsteroidal anti-inflammatory drug intake before admission does not have any impact. The initial CNF complications increased both the duration of mechanical ventilation and the length of stay in the ICU. On the basis of a multivariate analysis, the independent factors for severe complications are pharyngeal CNF and oral glucocorticoid intake before admission., Conclusions: Our study demonstrated that an initial cervico-thoracic CT scan revealed a high incidence of cervical and mediastinal CNF complications that all needed immediate management. Those severe complications might be avoidable as they were associated, at least partially, with prehospital oral glucocorticoid intake.

Purpose: To evaluate the feasibility of guidewire detection in right cardiac cavities by transthoracic echocardiography (TTE) in order to detect catheter misplacement and to optimize central venous catheter (CVC) positioning. Ultrasonic control for catheter tip positioning was compared to that by chest X-ray (CXR)., Methods: We conducted a monocentric prospective observational study (January-November 2010). All consecutive patients undergoing CVC insertion were included. The puncture was performed using the landmark method or ultrasound guidance. TTE was performed during the procedure to follow the arrival of the guidewire in the right cardiac cavities. Catheter misplacement was defined as an aberrant position on the postprocedural CXR (catheter positioning in ipsilateral or contralateral veins). The primary endpoint was the prediction of catheter misplacement by guidewire detection in the cardiac cavities. The secondary endpoint was the optimization of the catheter tip placement in the superior vena cava., Results: A total of 98 patients received 101 CVC. The guidewire was visualized in 92 cases. In five cases, the guidewire was not seen in the right cardiac cavities and CXR showed catheter misplacement. In four cases, poor echogenicity led to the ultrasound examination being abandoned. Catheter misplacement was detected by TTE with a sensitivity of 96% (CI 90-98%), a specificity of 83% (CI 44-97%), a positive predictive value of 98%, and a negative predictive value of 55%. Likelihood ratios were LR+ 5.7 (CI 0.96-34.4) and LR- 0.05 (CI 0.02-0.14). Guidewire removal under TTE avoided an excessively distal position of the catheter tip in all cases., Conclusion: TTE is a reliable tool to detect catheter misplacement and to optimize catheter tip positioning during the procedure of CVC insertion.

Objective: To evaluate the ability of DeltaPP/DeltaP [pulse pressure variations (DeltaPP) adjusted by alveolar pressure variations (DeltaP = Pplat-PEEPtot)] in predicting fluid responsiveness, to compare its accuracy to that of DeltaPP used alone and to evaluate the influence of tidal volume (Vt) on these two indices., Design: Prospective study., Setting: A 22-bed general intensive care unit (ICU)., Patients: Eighty-four surgical or medical ventilated patients requiring fluid challenge., Intervention: A 6 ml/kg colloid fluid challenge in 30 min., Measurements and Results: Hemodynamic measurements taken before and after fluid challenge. Patients separated into responders and nonresponders according to a 15% increase in their cardiac output. Thirty-nine patients found to be responders and 45 nonresponders. DeltaPP/DeltaP and DeltaPP were both higher in responders than in nonresponders. DeltaPP/DeltaP was a better predictor of fluid responsiveness than PP, especially for patients ventilated with Vt > or = 8 ml/kg [area under the curve (AUC) 0.88 (0.77-0.98) versus 0.75 (0.60-0.89), P < 0.01)]. In this population DeltaPP/DeltaP higher than 0.9 predicted fluid response with positive predictive value of 87% and negative predictive value of 78%. Overall DeltaPP and DeltaPP/DeltaP reliability was poor for patients ventilated with Vt < 8 ml/kg [AUC 0.63 (0.45-0.81) and 0.72 (0.55-0.88), respectively]., Conclusion: In this mixed ICU population PP adjusted by P is a simple index which outperforms DeltaPP for patients ventilated with Vt > or = 8 ml/kg. However, correcting DeltaPP by DeltaP still fails to predict fluid response reliably in patients ventilated with low tidal volume.

Objective: To test the hypothesis that, in resuscitated septic shock patients, central venous-to-arterial carbon dioxide difference [P(cv-a)CO(2)] may serve as a global index of tissue perfusion when the central venous oxygen saturation (ScvO(2)) goal value has already been reached., Design: Prospective observational study., Setting: A 22-bed intensive care unit (ICU)., Patients: After early resuscitation in the emergency unit, 50 consecutive septic shock patients with ScvO(2) > 70% were included immediately after their admission into the ICU (T0). Patients were separated in Low P(cv-a)CO(2) group (Low gap; n = 26) and High P(cv-a)CO(2) group (High gap; n = 24) according to a threshold of 6 mmHg at T0., Measurements: Measurements were performed every 6 h over 12 h (T0, T6, T12)., Results: At T0, there was a significant difference between Low gap patients and High gap patients for cardiac index (CI) (4.3 +/- 1.6 vs. 2.7 +/- 0.8 l/min/m(2), P < 0.0001) but not for ScvO(2) values (78 +/- 5 vs. 75 +/- 5%, P = 0.07). From T0 to T12, the clearance of lactate was significantly larger for the Low gap group than for the High gap group (P < 0.05) as well as the decrease of SOFA score at T24 (P < 0.01). At T0, T6 and T12, CI and P(cv-a)CO(2) values were inversely correlated (P < 0.0001)., Conclusion: In ICU-resuscitated patients, targeting only ScvO(2) may not be sufficient to guide therapy. When the 70% ScvO(2) goal-value is reached, the presence of a P(cv-a)CO(2) larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.

Objective: Esophageal Doppler allows continuous monitoring of stroke volume index (SVI) and corrected flow time (FTc). We hypothesized that variations in stroke output index SOI (SVI/FTc) during volume expansion can predict the hemodynamic response to subsequent fluid loading better than the static values., Design and Setting: Prospective study in the intensive care unit of a university hospital., Patients: Fifty-one patients with circulatory failure were monitored by esophageal Doppler., Interventions: Patients who responded to a first fluid challenge received a second one. Patients who responded to both were classified as responders-responders, and those who did not respond to the second as responders-nonresponders. In these two groups we compared DeltaSVI, DeltaFTc, and DeltaSOI during each fluid challenge and also static values at the end of each fluid challenge., Measurements and Results: After the first fluid challenge DeltaSOI and DeltaSVI were significantly higher in patients who responded to subsequent volume expansion than in patients who no longer responded. ROC curves showed that DeltaSOI was a better predictor of fluid responsiveness than DeltaSVI. During volume expansion a DeltaSOI value of 11% discriminated between responders and nonresponders to subsequent volume expansion with a sensitivity of 91% and a specificity of 97%. There was no significant difference between the two groups for FTc value at the end of first fluid challenge., Conclusions: Analysis of DeltaSOI during fluid challenge predicts response to subsequent fluid challenge and FTc is not a reliable indicator of cardiac preload.